BREAST SELF EXAMINATION

HOW TO DETECT BREAST CANCER

You are the best person to pick up on unusual changes in your breast. That's why it's important to perform breast self-exams (BSE) monthly. The goal of BSE is to become as familiar with your breasts as you are with your face or hands. Look for changes in the size and shape of either breast or any changes in skin color or texture. Differences in the size and shape of your breasts can be a normal variation and often are related to your menstrual cycle. Learn what is normal for you so that you can detect changes in your breasts.

Important changes to look for during a breast self-exam are nipple discharge, scaliness of the skin, puckering or dimpling of the skin or retraction of the nipple. Report any abnormalities to your health care provider immediately.

How To Perform Breast Self-exam

1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head.

2. Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening in your right breast. (Your finger pads are the top third of each finger.) Move around the breast in a circular motion, covering every inch of your breast tissue. Move up and down the breast vertically at least 10 times.

3. Press firmly enough to know how your breast feels. Learn what your breast feels like most of the time. A firm ridge in the lower curve of the breast is normal.

4. Now use the same method to examine your left breast using the finger pads of your right hand.

5. Stand in front of a mirror. Place your hands on your sides, on your hips and then lift them over your head. Look for changes in the size, shape, color or texture of your breasts. Keep in mind that it is normal for one breast to be slightly larger.

Breast Self Exam artwork reprinted by the permission of the American Cancer Society, Inc.

Tips for Successful Breast Self-exam

1. The best time to perform BSE is right after your period, when your breasts are not tender or swollen. If you do not have regular periods, do BSE on the same day every month.

2. You might want to do BSE while you're in the shower. Your soapy hands will glide over the wet skin, making it easier to check how your breasts feel.

3. Most breast cancers occur in the upper outer area of the breast. Pay close attention to this area when performing BSE.

Please remember that the material presented here is for informational purposes only. If you have specific questions about a medical imaging procedure, contact your physician or the radiology department of the institution where your test will be performed.

STOP SMOKING TIPS

1. Taking 1/2 teaspoon of baking soda 3 times a day will help you quit smoking. The soda neutralizes the body acids, retains nicotine in the blood, and thus reduces the desire for tobacco.

2. Eat plenty of fresh lemons and lemon juice to reduce your desire for cigarettes. Eating lots of salads and other fruits will also help. Avoid meat and alcohol.

3. To avoid irritability: take 1 tryptophan (667 mg.) tablet 3 times a day, plus 1 Vitamin B complex (100 mg., time release) with your evening meal.

4. Before breakfast, take 1/2 teaspoon each of Rochelle Salts and Cream of Tartar.

5. Try chewing Ginseng Root; swallow the juice.

6. Dont keep cigarettes by your bed. When you wake up, breathe deeply and brush your teeth right away.

7. Eliminate situations in which you normally smoke; for example, give up one coffee break each day. Exercise or go for a walk instead. After dinner, brush your teeth immediately or go for a brisk walk.

8. Dont take your cigarettes to work or anywhere else.

9. Always sit beside non-smokers in public situations such as meetings.

10. Always put away your cigarettes, lighter and ashtray so that getting them will require an effort.

11. Change your brand of cigarette often. Each week smoke a brand with a lower nicotine and tar content.

12. Switch to a brand of cigarette you dont like; change to filter if you prefer non-filter, menthol if you prefer regular.

13. Cut back on drinks which encourage your smoking habits; for example, eliminate lunchtime coffee.

14. Make a point of having your first cigarette a bit later each day. Stop smoking a little earlier each night.

15. Alternate between giving up a morning, afternoon and evening cigarette.

16. Avoid smoking in certain habitual places, for example, on the telephone, while watching TV or sitting with the newspaper.

17. Make a list of the reasons you want to quit and keep it with you all the time; whenever you feel the urge, read your list.

18. Always choose seats in No Smoking sections of restaurants, trains and other public places.

19. Initiate a 3-day program, each day smoking 1/2 of what you smoked the day before.

20. Limit your smoking to alternate hours; the next day or the next week increase your no-smoking periods to 1-1/2 hours; then increase them to 2 hours, etc., until you have stopped altogether.

Breast Cancer Detection

High-quality mammography is the most effective technology presently available for breast cancer screening. Efforts to improve mammography focus on refining the technology and improving how it is administered and x-ray films are interpreted. NCI is funding research to reduce the already low radiation dosage of mammography; enhance mammogram image quality; develop statistical techniques for computer-assisted interpretation of images; enable long-distance, electronic image transmission technology (telemammography/teleradiology) for clinical consultations; and improve image-guided techniques to assist with breast biopsies. (A breast biopsy is the removal of cells or tissues to look at under a microscope to check for signs of disease). NCI also supports research on technologies that do not use x-rays, such as magnetic resonance imaging (MRI), ultrasound, and breast-specific positron emission tomography (PET) to detect breast cancer. The following information describes the latest imaging techniques that are in use or being studied.

Ultrasound

Ultrasound, also called sonography, is an imaging technique in which high-frequency sound waves that cannot be heard by humans are bounced off tissues and internal organs. Their echoes produce a picture called a sonogram. Ultrasound imaging of the breast is used to distinguish between solid tumors and fluid-filled cysts. Ultrasound can also be used to evaluate lumps that are hard to see on a mammogram. Sometimes, ultrasound is used as part of other diagnostic procedures, such as fine needle aspiration (also called needle biopsy). Fine needle aspiration is the removal of tissue or fluid with a needle for examination under a microscope to check for signs of disease.

During an ultrasound examination, the clinician spreads a thin coating of lubricating jelly over the area to be imaged to improve conduction of the sound waves. A hand-held device called a transducer directs the sound waves through the skin toward specific tissues. As the sound waves are reflected back from the tissues within the breast, the patterns formed by the waves create a two-dimensional image of the breast on a computer.

Ultrasound is not used for routine breast cancer screening because it does not consistently detect certain early signs of cancer such as microcalcifications (tiny deposits of calcium in the breast that cannot be felt but can be seen on a conventional mammogram). A cluster of microcalcifications may indicate that cancer is present.

Digital Mammography

Digital mammography is a technique for recording x-ray images in computer code instead of on x-ray film, as with conventional mammography. The images are displayed on a computer monitor and can be enhanced (lightened or darkened) before they are printed on film. Images can also be manipulated; the radiologist (a doctor who specializes in creating and interpreting pictures of areas inside the body) can magnify or zoom in on an area. From the patient’s perspective, the procedure for a mammogram with a digital system is the same as for conventional mammography.

Digital mammography may have some advantages over conventional mammography. The images can be stored and retrieved electronically, which makes long-distance consultations with other mammography specialists easier. Because the images can be adjusted by the radiologist, subtle differences between tissues may be noted. The improved accuracy of digital mammography may reduce the number of followup procedures. Despite these benefits, studies have not yet shown that digital mammography is more effective in finding cancer than conventional mammography.

The first digital mammography system received U.S. Food and Drug Administration (FDA) approval in 2000. An example of a digital mammography system is the Senographe® 2000D. Women considering digital mammography should talk with their doctor or contact a local FDA-certified mammography center to find out if this technique is available at that location. Only facilities that have been certified to practice conventional mammography and have FDA approval for digital mammography may offer the digital system. A list of conventional mammography facilities is available by calling the Cancer Information Service at 1–800–4–CANCER (1–800–422–6237), or by visiting the FDA Web site at http://www.fda.gov/cdrh/mammography/certified.html on the Internet.

Computer-Aided Detection

Computer-aided detection (CAD) involves the use of computers to bring suspicious areas on a mammogram to the radiologist’s attention. It is used after the radiologist has done the initial review of the mammogram.

In 1998, the FDA approved a breast imaging device that uses CAD technology. Others are in development. An example of a breast imaging device that uses CAD technology is the ImageChecker®. This device scans the mammogram with a laser beam and converts it into a digital signal that is processed by a computer. The image is then displayed on a video monitor, with suspicious areas highlighted for the radiologist to review. The radiologist can compare the digital image with the conventional mammogram to see if any of the highlighted areas were missed on the initial review and require further evaluation. CAD technology may improve the accuracy of screening mammography. The incorporation of CAD technology to digital mammography is under evaluation.

MRI

In magnetic resonance imaging (MRI), a magnet linked to a computer creates detailed pictures of areas inside the body without the use of radiation. Each MRI produces hundreds of images of the breast from side-to-side, top-to-bottom, and front-to-back. The images are then interpreted by a radiologist.

During an MRI of the breast, the patient lies on her stomach on the scanning table. The breast hangs into a depression or hollow in the table, which contains coils that detect the magnetic signal. The table is moved into a tube-like machine that contains the magnet. After an initial series of images has been taken, the patient may be given a contrast agent intravenously (by injection into a vein). The contrast agent is not radioactive; it is sometimes used to improve the visibility of a tumor. Additional images are then taken. The entire imaging session takes about 1 hour.

Breast MRI is not used for routine breast cancer screening, but clinical trials (research studies with people) are being performed to determine if MRI is valuable for screening certain women, such as young women at high risk for breast cancer. MRI cannot always accurately distinguish between cancer and benign (noncancerous) breast conditions. Like ultrasound, MRI cannot detect microcalcifications.

MRI is used primarily to evaluate breast implants for leaks or ruptures, and to assess abnormal areas that are seen on a mammogram or are felt after breast surgery or radiation therapy. It can be used after breast cancer is diagnosed to determine the extent of the tumor in the breast. MRI is also sometimes useful in imaging dense breast tissue, which is often found in younger women, and in viewing breast abnormalities that can be felt but are not visible with conventional mammography or ultrasound.

PET Scan

The positron emission tomography (PET) scan creates computerized images of chemical changes that take place in tissue. The patient is given an injection of a substance that consists of a combination of a sugar and a small amount of radioactive material. The radioactive sugar can help in locating a tumor, because cancer cells take up or absorb sugar faster than other tissues in the body.

After receiving the radioactive drug, the patient lies still for about 45 minutes while the drug circulates throughout the body. If a tumor is present, the radioactive sugar will accumulate in the tumor. The patient then lies on a table, which gradually moves through the PET scanner 6 to 7 times during a 45-minute period. The PET scanner is used to detect the radiation. A computer translates this information into the images that are interpreted by a radiologist.

PET scans may play a role in determining whether a breast mass is cancerous. However, PET scans are more accurate in detecting larger and more aggressive tumors than they are in locating tumors that are smaller than 8 mm and/or less aggressive. They may also detect cancer when other imaging techniques show normal results. PET scans may be helpful in evaluating and staging recurrent disease (cancer that has come back).

An NCI-sponsored clinical trial is evaluating the usefulness of PET scan results in women who have breast cancer compared with the findings from other imaging and diagnostic techniques. This trial is also studying the effectiveness of PET scans in tracking the response of a tumor to treatment.

Electrical Impedance Scanning

Different types of tissue have different electrical impedance levels (electrical impedance is a measurement of how fast electricity travels through a given material). Some types of tissue have high electrical impedance, while others have low electrical impedance. Breast tissue that is cancerous has a much lower electrical impedance (conducts electricity much better) than normal breast tissue. Electrical impedance scanning devices are used along with conventional mammography to detect breast cancer. The T-Scan 2000, also known as the T-Scan, is an example of such a device. The FDA approved the T-Scan 2000 in 1999.

The electrical impedance scanning device, which does not emit any radiation, consists of a hand-held scanning probe and a computer screen that displays two-dimensional images of the breast. An electrode patch, similar to that used for an electrocardiogram, is placed on the patient’s arm. A very small amount of electric current, about the same amount used by a small penlight battery, is transmitted through the patch and into the body. The current travels through the breast, where it is measured by the scanning probe placed over the breast. An image is generated from the measurements of electrical impedance. Because breast cancer cells conduct electricity better than normal breast cells and tend to have lower electrical impedance, breast tumors may appear as bright white spots on the computer screen.

This device can confirm the location of abnormal areas that were detected by a conventional mammogram. The scanner sends the image directly to a computer, allowing the radiologist to move the probe around the breast to get the best view of the area being examined. The device may reduce the number of biopsies needed to determine whether a mass is cancerous. It may also improve the identification of women who should have a biopsy.

The scanner is not approved as a screening device for breast cancer, and is not used when mammography or other findings clearly indicate the need for a biopsy. This device has not been studied with patients who have implanted electronic devices, such as pacemakers. It is not recommended for use on such patients.

Image-Guided Breast Biopsy Techniques

Imaging techniques play an important role in helping doctors perform breast biopsies, especially of abnormal areas that cannot be felt but can be seen on a conventional mammogram or with ultrasound. One type of needle biopsy, the stereotactic-guided biopsy, involves the precise location of the abnormal area in three dimensions using conventional mammography. (Stereotactic refers to the use of a computer and scanning devices to create three-dimensional images.) A needle is then inserted into the breast and a tissue sample is obtained. Additional samples can be obtained by moving the needle within the abnormal area.

Another type of needle biopsy uses a different system, known as the Mammotome® breast biopsy system. The FDA approved Mammotome in 1996; the hand-held version of the Mammotome received FDA clearance in September 1999. A large needle is inserted into the suspicious area using ultrasound or stereotactic guidance. The Mammotome is then used to gently vacuum tissue from the suspicious area. Additional tissue samples can be obtained by rotating the needle. This procedure can be performed with the patient lying on her stomach on a table. If the hand-held device is used, the patient may lie on her back or in a seated position.

There have been no reports of serious complications resulting from the Mammotome breast biopsy system. Women interested in this procedure should talk with their doctor.

Ductal Lavage

Ductal lavage is an investigational technique for collecting samples of cells from breast ducts for analysis under a microscope. A saline (salt water) solution is introduced into a milk duct through a catheter (a thin, flexible tube) that is inserted into the opening of the duct on the surface of the nipple. Fluid, which contains cells from the duct, is withdrawn through the catheter. The cells are checked under a microscope to identify changes that may indicate cancer or changes that may increase the risk for breast cancer. The usefulness of ductal lavage is still under study.

QUIT CIGARETTE SMOKING

Here are some facts to encourage you to QUIT SMOKING

Key Points Cigarette smoking causes 87 percent of lung cancer deaths and is responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder (see Question 1). Secondhand smoke is responsible for an estimated 3,000 lung cancer deaths among U.S. nonsmokers each year (see Question 2). Tobacco smoke contains thousands of chemical agents, including over 60 substances that are known to cause cancer (see Question 3). The risk of developing smoking-related cancers, as well as noncancerous diseases, increases with total lifetime exposure to cigarette smoke (see Question 4). Smoking cessation has major and immediate health benefits, including decreasing the risk of lung and other cancers, heart attack, stroke, and chronic lung disease (see Question 5).

Tobacco use, particularly cigarette smoking, is the single most preventable cause of death in the United States. Cigarette smoking alone is directly responsible for approximately 30 percent of all cancer deaths annually in the United States (1). Cigarette smoking also causes chronic lung disease (emphysema and chronic bronchitis), cardiovascular disease, stroke, and cataracts. Smoking during pregnancy can cause stillbirth, low birthweight, Sudden Infant Death Syndrome (SIDS), and other serious pregnancy complications (2). Quitting smoking greatly reduces a person’s risk of developing the diseases mentioned, and can limit adverse health effects on the developing child.

1. What are the effects of cigarette smoking on cancer rates?

Cigarette smoking causes 87 percent of lung cancer deaths (1). Lung cancer is the leading cause of cancer death in both men and women (3). Smoking is also responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder. In addition, it is a cause of kidney, pancreatic, cervical, and stomach cancers (2, 4), as well as acute myeloid leukemia (2).

2. Are there any health risks for nonsmokers?

The health risks caused by cigarette smoking are not limited to smokers. Exposure to secondhand smoke, or environmental tobacco smoke (ETS), significantly increases the risk of lung cancer and heart disease in nonsmokers, as well as several respiratory illnesses in young children (5). (Secondhand smoke is a combination of the smoke that is released from the end of a burning cigarette and the smoke exhaled from the lungs of smokers.) The U.S. Environmental Protection Agency (EPA), the National Institute of Environmental Health Science’s National Toxicology Program, and the World Health Organization’s International Agency for Research on Cancer (IARC) have all classified secondhand smoke as a known human carcinogen—a category reserved for agents for which there is sufficient scientific evidence that they cause cancer (5, 6, 7). The U.S. EPA has estimated that exposure to secondhand smoke causes about 3,000 lung cancer deaths among nonsmokers and is responsible for up to 300,000 cases of lower respiratory tract infections in children up to 18 months of age in the United States each year (5). For additional information on ETS, see the NCI fact sheet Environmental Tobacco Smoke, which can be found at http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS on the Internet.

3. What harmful chemicals are found in cigarette smoke?

Cigarette smoke contains about 4,000 chemical agents, including over 60 carcinogens (8). In addition, many of these substances, such as carbon monoxide, tar, arsenic, and lead, are poisonous and toxic to the human body. Nicotine is a drug that is naturally present in the tobacco plant and is primarily responsible for a person’s addiction to tobacco products, including cigarettes. During smoking, nicotine is absorbed quickly into the bloodstream and travels to the brain in a matter of seconds. Nicotine causes addiction to cigarettes and other tobacco products that is similar to the addiction produced by using heroin and cocaine (9).

4. How does exposure to tobacco smoke affect the cigarette smoker?

Smoking harms nearly every major organ of the body (2). The risk of developing smoking-related diseases, such as lung and other cancers, heart disease, stroke, and respiratory illnesses, increases with total lifetime exposure to cigarette smoke (7). This includes the number of cigarettes a person smokes each day, the intensity of smoking (i.e., the size and frequency of puffs), the age at which smoking began, the number of years a person has smoked, and a smoker’s secondhand smoke exposure.

5. How would quitting smoking affect the risk of developing cancer and other diseases?

Smoking cessation has major and immediate health benefits for men and women of all ages. Quitting smoking decreases the risk of lung and other cancers, heart attack, stroke, and chronic lung disease. The earlier a person quits, the greater the health benefit. For example, research has shown that people who quit before age 50 reduce their risk of dying in the next 15 years by half compared with those who continue to smoke (3). Smoking low-yield cigarettes, as compared to cigarettes with higher tar and nicotine, provides no clear benefit to health (2). For additional information on quitting smoking, see the NCI fact sheet Questions and Answers About Smoking Cessation, which can be found at http://www.cancer.gov/cancertopics/factsheet/Tobacco/cessation on the Internet.

6. What additional resources are available?

For additional information about cancer or tobacco use, call 1–800–4–CANCER or visit the NCI’s Web site about tobacco at http://www.cancer.gov/cancerinfo/tobacco on the Internet.

For help with quitting smoking, call NCI’s smoking cessation quitline at 1–877–44U–QUIT or visit NCI’s smoking cessation Web site at http://www.smokefree.gov on the Internet.

Information about the health risks of smoking is also available from Centers for Disease Control and Prevention’s Office on Smoking and Health (OSH) at 1–800–CDC–1311 (1–800–232–1311) or via their Web site at http://www.cdc.gov/tobacco on the Internet.

these questions and facts were aimed at creating a general awareness about the ill effects of smoking . To learn the methodical way to quit smoking please visit QUIT SMOKING

Mesothelioma

Questions and Answers

Mesothelioma is a rare form of cancer in which malignant (cancerous) cells are found in the mesothelium, a protective sac that covers most of the body’s internal organs. Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles.

1. What is the mesothelium?

The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs) to glide easily against adjacent structures.

The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The mesothelial tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.

2. What is mesothelioma?

Mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.

3. How common is mesothelioma?

Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.

4. What are the risk factors for mesothelioma?

Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos.

Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. Asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.

Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person’s risk of developing cancer of the air passageways in the lung.

5. Who is at increased risk for developing mesothelioma?

Asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.

The risk of asbestos-related disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma. On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.

There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.

6. What are the symptoms of mesothelioma?

Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to asbestos. Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.

These symptoms may be caused by mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis.

7. How is mesothelioma diagnosed?

Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient’s medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.

A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.

If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.

Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.

8. How is mesothelioma treated?

Treatment for mesothelioma depends on the location of the cancer, the stage of the disease, and the patient’s age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.

• Surgery is a common treatment for mesothelioma. The doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural mesothelioma), a lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
• Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumors. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).
• Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat mesothelioma are given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).

To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation therapy and surgery may also be helpful in relieving symptoms.

9. Are new treatments for mesothelioma being studied?

Yes. Because mesothelioma is very hard to control, the National Cancer Institute (NCI) is sponsoring clinical trials (research studies with people) that are designed to find new treatments and better ways to use current treatments. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease. Participation in clinical trials is an important treatment option for many patients with mesothelioma.

People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the Cancer Information Service (CIS) (see below) at 1–800–4–CANCER. Information specialists at the CIS use PDQ®, NCI’s cancer information database, to identify and provide detailed information about specific ongoing clinical trials. Patients also have the option of searching for clinical trials on their own. The clinical trials page on the NCI’s Cancer.gov Web site, located at http://www.cancer.gov/clinical_trials on the Internet, provides general information about clinical trials and links to PDQ.

People considering clinical trials may be interested in the NCI booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know. This booklet describes how research studies are carried out and explains their possible benefits and risks. The booklet is available by calling the CIS, or from the NCI Publications Locator Web site at http://www.cancer.gov/publications on the Internet.

FDA medicine Tips

FDA's Tips for Taking Medicines

How to Get the Most Benefits with the Fewest Risks

Whether prescription or over-the-counter (OTC), no medicine is without risk. Besides benefits, medicines may cause side effects or allergic reactions, and they may be affected by interactions with foods, drinks, or other drugs.

For prescription drugs, a patient's first step to safe and effective treatment is to ask the doctor questions with each new prescription. For example:

• What is the medicine's name, and what is it supposed to do?
• How and when do I take it, and for how long?
• While taking this medicine, should I avoid:
  • certain foods or dietary supplements?
  • caffeine, alcohol, or other beverages?
  • other medicines, prescription and OTC?
  • certain activities, such as driving or smoking?
• Will this new medicine work safely with prescription and OTC medicines I'm already taking?
• Are there side effects, and what do I do if they occur?
• Will the medicine affect my sleep or activity level?
• What should I do if I miss a dose?
• Is there written information available about the medicine? (At the very least, ask the doctor or pharmacist to write out complicated directions and medicine names.)

It's wise to write down the answers to these questions immediately, to make sure you'll remember all the details.

Some patients need to overcome being nervous about asking these questions, says Ellen Tabak, Ph.D., of the Food and Drug Administration's division of drug marketing, advertising and communications. In Tabak's research before coming to FDA, patients who asked questions were more satisfied with their medical visits.

Pharmacist Michael Cohen, president of the Institute for Safe Medication Practices, Warminster, Pa., adds, "If you can't ask questions comfortably, get someone to do it for you. There are patient advocates in the hospital, and relatives or friends on the outside."

And, "to prevent mix-ups, patients ought to insist that the medicine's purpose be put on the label," Cohen adds.

Here are more tips for helping your medicines work as safely and effectively as possible.

General Advice

• Keep a record of all your current medicines, including their names and regimens (dose, time, and other instructions for taking). Write down any problems you have with the medicine so you can discuss them with your doctor or pharmacist.
• Using adequate light, read labels carefully before taking doses.
• Ask the doctor's or pharmacist's advice before crushing or splitting tablets; some should only be swallowed whole.
• Contact the doctor or pharmacist if new or unexpected symptoms or other problems appear.
• Never stop taking medicine the doctor has told you to finish just because symptoms disappear.
• Ask the doctor periodically to reevaluate long-term treatments.
• If you have questions, talk to your pharmacist or doctor before using an OTC medicine the first time, especially if you use other medicine.
• Carefully read OTC medicine labels for ingredients, proper uses, directions, warnings, precautions, and expiration dates. Many medicines contain the same ingredients. Be sure you're not taking the same drug in more than one form.
• Discard outdated medicine.
• Store medicine in the original container, where the label identifies it and gives directions.
• Never store medicine in the bathroom. Unless instructed otherwise, keep it away from heat, light and moisture.
• Never store medicine near a dangerous substance, which could be taken by mistake.
• Never take someone else's medicine.
• Tell your health professional if you:
  • are breast-feeding or are, or may be, pregnant
  • are allergic to drugs or foods
  • have diabetes or kidney or liver disease
  • take other prescription or OTC medicines regularly
  • follow a special diet or take dietary supplements
  • use alcohol or tobacco.

Children and Medicine

• Keep all medicine out of children's reach. Some medicines, such as iron supplements, are very toxic to children.
• Use child-resistant caps, and never leave containers uncapped.
• Examine dose cups carefully. Cups may be marked with various measurement units and may not use standard abbreviations. Follow label directions. Never substitute a cup from another product.
• When using a dosing syringe with a cap, discard the cap before use.
• Never guess when converting measuring units--from teaspoons or tablespoons to ounces, for example. Consult a reliable source, such as the pharmacist.
• Never try to remember the dose used during previous illnesses; read the label each time.
• Check with the doctor or pharmacist before giving a child more than one medicine at a time.
• Never give medicine to children unless it is recommended for them on the label or by a doctor. Don't give children drugs intended for adults; children's doses are almost always lower.
• Never use medicine for purposes not mentioned on the label, unless so directed by a doctor.
• Check with the doctor before giving a child aspirin products. Never give aspirin to a child or teenager who has or is recovering from chickenpox, flu symptoms (nausea, vomiting or fever), or flu. Aspirin may be associated in such patients with an increased risk of Reye syndrome, a rare but serious illness.

Protect Against Tampering

• Read the label about the product's tamper-evident features.
• Look at the package for tampering signs such as broken seals, puncture holes, or open or damaged wrappings.
• Look at the medicine. Never take medicine that is discolored, has an unusual odor, or seems suspicious in some other way. Check with the pharmacist if you have any questions.
• Return suspicious medicine to the store manager or pharmacist.
• Look again when you take a dose. Never take medicine if you're not alert or can't see clearly.

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Containers That Count, Bottles That Beep,
and Other Helpful Gizmos

A medicine container that beeps when it's time for a dose, a computerized drug organizer-dispenser, and a special cap that counts openings of a prescription vial to tell if the day's doses have been taken are among the aids available for consumers who feel they need some extra help to take their medicines correctly.

These and other aids are listed in a catalog from the National Council on Patient Information and Education, Washington, D.C., from which pharmacists can order.

Pharmacies commonly carry simple compliance aids such as drug containers with compartments labeled for meals and bedtime (some with Braille markings) and spoons and syringes clearly marked with doses for liquid medications.

While convenience containers aid compliance by helping to organize medicines in advance, it's a good idea to ask the pharmacist whether the container you're planning to use will affect the stability of your medicine.

Even with one day's poor storage, tablets containing certain medicines could break down. It depends on where the medicine is stored and how sensitive it is to moisture, light or oxygen. Pharmacists consider a medicine's particular sensitivities when selecting its prescription container.

Medicine storage "can be a significant problem when you carry medicine around in a poorly sealed container under high humidity, as occurs along the Gulf Coast," says L. Timothy Grady, Ph.D., vice president and director of standard development at the U.S. Pharmacopeia, an independent standards-setting organization. "Carrying medicine in a pocket next to the body can raise the temperature."

As some medicines break down, Grady says, they may no longer dissolve properly, and the body therefore can't use them.

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Preventing Medicine Misuse

Up to half of the people who use medicines don't use them as prescribed.

That's a lot of medicine misuse, considering that pharmacists dispensed some 2.4 billion prescriptions in 1996, according to the National Prescription Audit by IMS America Ltd., of Plymouth Meeting, Pa.

And the results of misuse can be tragic. Missed doses of glaucoma medicine, for example, can lead to optic nerve damage or blindness. Missed doses of heart medicine can lead to cardiac arrest.

Better Written Information

To help prevent medicine misuse, health professionals now voluntarily distribute leaflets that give patients more and better information about their prescription drugs. The leaflets were prompted by the "Action Plan for the Provision of Useful Medicine Information." Health professionals and consumer, government and industry representatives helped develop the plan.

Information in the leaflets must include the medicine's uses approved by FDA, directions for correct use, and possible side effects. They must be scientifically accurate, unbiased, specific, complete, understandable, up-to-date, and useful.

"But the criteria aren't set in stone," says pharmacist Thomas McGinnis, the FDA's director of pharmacy affairs. For example, the format may be adjusted for older people, who may need larger type because of failing eyesight. And doctors or pharmacists may add information about a use not approved by the FDA (or "off-label" use) when necessary for an individual patient. With computer software on medicine information widely available, McGinnis says pharmacists can easily generate the leaflets.

This information must reach at least 75 percent of patients by the year 2000, and at least 95 percent of patients by 2006. The FDA will survey consumers nationwide in those years to determine whether the goals have been met, and will sample the patient labeling to evaluate whether it provides the required information in simple language.

The Right to Counseling

In addition, the Centers for Medicare and Medicaid Services (CMS)--formerly known as the Health Care Financing Administration--requires pharmacists or their assistants to offer prescription medicine counseling to Medicaid patients and review their medicine usage. Mail-order pharmacies must provide toll-free telephone service.

CMS health insurance specialist Christina Lyon says the offer to counsel must include all important aspects of the medicine, such as its description, dosage form, length of treatment, special directions, common severe side effects, interactions and their avoidance or remedy, storage, the way to handle a missed dose, and techniques for self-monitoring treatment, such as blood testing by diabetics.

The vast majority of states have extended the CMS's rules to give all patients a legal right to counseling on their medicines, says Carmen Catizone, executive director of the National Association of Boards of Pharmacy.

"Patients should exercise that right," he says, "to make sure they've received the correct medicine and that they completely understand how to take that medicine and what side effects there may be."

Talk to your doctor

Past is the era when doctors were looked upon as "Gods" and their words were taken as gospel truth. Today there is a general feeling of skepticism in patients towards medical profession. In such background the interaction and conversation between a patient and doctor can be really confusing for the patient and his kin.

It is important that the patients and their kin take an active role in their treatment. They should work in close coordination with the doctor to achieve the best possible treatment. An important part of this relationship is good communication. Here are some questions you can ask your doctor to get your discussion started:

About the Disease or Disorder...

• What is my diagnosis?
• What caused my condition?
• Can my condition be treated?
• How will this condition affect my vision now and in the future?
• Should I watch for any particular symptoms and notify you if they occur?
• Should I make any lifestyle changes?

About the Treatment...

• What is the treatment for my condition?
• When will the treatment start, and how long will it last?
• What are the benefits of this treatment, and how successful is it?
• What are the risks and side effects associated with this treatment?
• Are there foods, drugs, or activities I should avoid while I'm on this treatment?
• If my treatment includes taking a medication, what should I do if I miss a dose?
• Are other treatments available?

About the Tests...

• What kinds of tests will I have?
• What do you expect to find out from these tests?
• When will I know the results?
• Do I have to do anything special to prepare for any of the tests?
• Do these tests have any side effects or risks?
• Will I need more tests later?

Understanding doctor's words:

• If you don't understand your doctor's responses, ask questions until you do understand.
• Take notes, or get a friend or family member to take notes for you. Or, bring a tape-recorder to assist in your recollection of the discussion (but you are required to take your doctor's permission to record the conversation).
• Ask your doctor to write down his or her instructions to you.
• Ask your doctor for printed material about your condition.
• If you still have trouble understanding your doctor's answers, ask where you can go for more information.

Getting the best from Your Doctor...

• Well, it is important to have the right perspective towards the doctor and the treatment.
• Remember that every doctor tries to do his best to treat his patient because a satisfied patient mean an advancement of practice.
• Stick to one doctor as far as possible. However, you may seek second opinion in consultation with your current physician. Consulting many doctors may cause confusion, dissatisfaction and delay in treatment.
• Pay him his dues. Remember you are paying for his skill, service and expertise, and for your own good health ........ things that are actually more valuable than most material objects.
• Take complications objectively. Complications are NOT deliberate blunders of doctors. Nobody ever wants things to go wrong, least of all doctors.
• Doctors know that good service and good treatment results for the patients mean good 'business sense' for the doctor.
• "Keep the Faith!"

Bad Day at the office! (COMPILATION VIDEO)

Diabetes and pregnancy

Definition

Diabetes is a condition in which glucose (a blood sugar that supplies the body with energy) cannot work properly because of a problem with insulin production or use in the body. Insulin is a hormone produced by the pancreas to regulate blood glucose levels. It works like a key that opens the cells in our bodies to accept glucose, thus providing us with energy.

There are two types of diabetes: type 1 and type 2. With type 1, the pancreas produces either little or no insulin to meet the body's needs. With type 2, the body cannot properly use the insulin it produces or produces too little insulin. With both types, the sugar stays in the bloodstream rather than passing into the cells, causing hyperglycemia (high blood sugar), which can damage a variety of body systems.

Pregnancy and diabetes

If you have diabetes and become pregnant, you face a greater risk of developing serious complications during pregnancy. Prepregnancy planning and prenatal care are essential in reducing this risk.

During pregnancy, your body may not produce enough insulin to meet its needs as well as the additional needs of your growing baby. As the baby develops, it needs more energy. As a result, your body needs more insulin to transform sugar into energy. If your blood sugar is higher than normal when the baby is born, the excess sugar is passed on to your infant and may cause medical complications.

During pregnancy, a mother who has diabetes has an increased risk of:

• miscarriage
• pregnancy-induced high blood pressure
• urinary tract, kidney and vaginal yeast infections
• stillbirth, sometimes without an identifiable cause
• preterm birth
• cesarean delivery

The baby has an increased risk of:

• serious birth defects, such as heart, brain, spinal cord, kidney or intestinal malformations
• hydramnios (excessive amniotic fluid)
• macrosomia (excessive weight at birth that can increase the risk of birth injuries)
• insufficient weight at birth
• if born prematurely, breathing difficulty
• low blood sugar after birth
• newborn jaundice (yellowing of the skin or whites of the eyes)
• obesity in childhood and possibly during adult life
• diabetes later in life

Two major factors influence the development of these risk factors, including:

• your ability to control your blood sugar during the three to six months before pregnancy and during the pregnancy itself
• the severity of any blood vessel damage that may have been caused by your diabetes

To reduce the risk of complications, careful prepregnancy planning and prenatal care are essential when you have diabetes. It's important to keep your blood sugar levels normal for several months before pregnancy -- and to maintain this control until your child is born. With proper care, you have nearly the same chances of having a healthy baby as a woman without diabetes.

Signs/symptoms

If your blood sugar level is too high (hyperglycemia), you may experience:

• increased thirst
• frequent urination
• weight loss despite an increase in appetite
• extreme fatigue and lack of energy
• nausea and vomiting
• blurred vision

If your blood sugar level is too low (hypoglycemia), you may experience the following mild symptoms, often with little warning:

• shakiness
• dizziness
• sweating
• irritability
• hunger
• heart palpitations or rapid heartbeat

Moderate to severe symptoms may include:

• headache
• difficulty concentrating or confusion
• poor coordination
• unusual behavior patterns such as stubbornness or uncooperativeness (may resemble a state of intoxication)
• eventually, stupor or unconsciousness

Diagnosis

To help ensure a safe, healthy pregnancy, your doctor may do a number of diagnostic tests before and during your pregnancy. Before conception, you'll have an eye exam and urine studies. If your pregnancy is unplanned, these tests will be done as early in the pregnancy as possible. A blood test called hemoglobin A1C (HgbA1C) can help the doctor determine how well controlled your blood sugar was in the three to four months before conception. The goal for this test is a result less than 7 percent, with 4 to 6 percent considered optimal.

During pregnancy, other tests may include:

• home testing of blood sugar levels four or more times a day
• a maternal serum alpha fetoprotein test (a blood test) at 16 to 20 weeks after conception to indicate the risk of certain birth defects
• an ultrasound (using sound waves to create images of internal body parts) at 16 to 20 weeks to check for birth defects, as well as accurately date the pregnancy
• nonstress tests to monitor your baby's heart rate at least weekly during the third trimester
• HbA1C test at least monthly
• measuring urine ketones (the end product of fat metabolism) each morning
• other tests, depending on the needs of you and your baby

Treatment

Your diabetes may be managed by a team of health care specialists during your pregnancy, possibly including an obstetrician specializing in high-risk pregnancy, an endocrinologist (a doctor who specializes in treating disorders of the hormone-producing endocrine glands), a dietitian, a diabetic educator and a pediatrician specializing in high-risk newborns. Your health care team will design a treatment plan to fit your specific needs, including a combination of proper diet, regular exercise and insulin. The goal of treatment is to keep your blood sugar as close to normal as possible.

Diet

Dietary counseling is an important part of your treatment plan. There are no universal dietary standards for pregnant women who have diabetes. Your doctor will help you plan a diet that takes both your pregnancy and diabetes into account. The required number of calories may need to be adjusted depending on your needs at particular points during the pregnancy. For example, you may need fewer calories during the first 12 weeks of pregnancy.

Starches (breads, grains and starchy vegetables)
Six to 11 servings per day
One serving:

• one slice of bread
• half bagel or English muffin
• one plain rice cake
• six crackers (such as rye crisps or saltines)
• 6-inch tortilla
• 3/4 cup dry cereal
• 1/3 cup rice
• 1/2 cup pasta or cooked cereal
• 1/2 cup corn, cooked beans, lentils or peas
• one small, plain baked potato
• 1 cup winter squash
• 1/2 cup sweet potato or yam

Fruits
Two to four servings per day
One serving:

• one small fruit (apple, orange, banana or peach)
• one melon wedge
• 1/2 cup chopped, cooked, frozen or unsweetened canned fruit
• 2 tablespoons dried fruit
• 1/2 cup fruit juice

Vegetables
Three to five or more servings per day
One serving:

• 1/2 cup cooked or chopped raw vegetables
• 1 cup leafy, raw vegetables
• 1/2 cup tomato or vegetable juice

Milk and yogurt
Two to three servings per day
One serving:

• 1 cup low-fat milk
• 1 cup soy milk
• 1 cup low-fat, unsweetened yogurt

Protein (meat and meat substitutes)
Two to three servings per day
One serving:

• 2 to 3 ounces cooked lean meat or poultry or fish
• 2 ounces cheese
• 1/2 cup tofu
• one egg or equivalent egg substitute
• 2 tablespoons peanut butter

Fats and oils
Fats and oils supply mostly calories and few nutrients, so use them sparingly. Foods in this group include salad dressing, oil, cream, butter, margarine, gravy and cream cheese. One serving is 1 tablespoon of regular salad dressing, 2 tablespoons of light salad dressing, 1 tablespoon of light mayonnaise, and 1 teaspoon of regular margarine or oil.

Sugary foods
Small amounts of sugary foods can be worked into a meal plan as carbohydrates. As with fats and oils, however, sugary foods are low in nutrients and high in fat. Use them sparingly.

Exercise
Exercise can help you stay healthy during pregnancy. Moderate aerobic exercise, such as walking or swimming for 20 to 30 minutes three times a week, can help control your blood sugar. Discuss any exercises with your doctor first, however, because some may not be safe in your situation.

Insulin
It's important to tightly control your blood sugar (keep it as close to normal as possible). Because insulin does not cross the placenta (the structure that develops in the uterus during pregnancy to nourish the fetus), it's safe to take insulin injections while you're pregnant. Oral diabetes medications have not been used during pregnancy due to possible harm to the fetus.

Blood glucose levels and the amount of required insulin tend to be unstable during the first trimester (first three months). The situation often stabilizes during the second trimester, but the need for insulin during the third trimester typically rises steadily. Sometimes, the need for insulin doubles or triples during the third trimester.

Because insulin requirements vary throughout pregnancy, you'll need close monitoring and follow-up. Your doctor will recommend the right amount of insulin to help control your blood sugar. You may need to have several insulin injections each day and measure your blood sugar at home several times a day, often upon awakening, and before or after meals. For some women whose blood sugar cannot be controlled with insulin injections, an insulin pump that delivers insulin automatically according to your changing needs may be recommended.

Labor and delivery

Most pregnant women who keep their blood sugar in the normal range and do not have medical complications can deliver at or near full term. During labor and delivery and in the early postpartum period (after the baby is born), the doctor will closely monitor your blood sugar levels and provide any needed insulin. After delivery, you may not need much insulin for the first days. Your baby will also be closely monitored for low blood sugar levels, jaundice and other possible health problems.

If your doctor recommends an early delivery because of the baby's large size or other complications, the baby's lung maturity will probably be tested. Labor is sometimes induced with medication. In some cases, cesarean delivery may be necessary.

Complications

Hypoglycemia (low blood sugar) is most common during the early weeks of pregnancy, especially between 10 and 15 weeks after conception. It's important for family members and other close contacts to be aware of the signs, symptoms and treatment of hypoglycemia. As listed above, mild symptoms of hypoglycemia -- which can occur with little warning -- include:

• shakiness
• dizziness
• sweating
• irritability
• hunger
• heart palpitations or rapid heartbeat

Moderate to severe symptoms may include:

• headache
• difficulty concentrating or confusion
• poor coordination
• unusual behavior patterns such as stubbornness or uncooperativeness (may resemble a state of intoxication)
• eventually, stupor or unconsciousness

To prevent hypoglycemia, do not miss or delay meals, and keep a source of sugar with you at all times.

In contrast to hypoglycemia, ketoacidosis is an emergency condition that develops when diabetes is uncontrolled. The blood sugar gets too high and there's not enough insulin to move the sugar into cells for energy. To get energy, the body breaks down its store of fat. This process, called ketosis, produces an excessive accumulation of ketones in the blood and tissues. As the level of ketones rises, other chemicals in the body become unbalanced and lead to ketoacidosis. The condition is most common in people who have type 1 diabetes. It's often due to missed doses of insulin, infection or serious illness. Ketoacidosis is associated with a significant infant death rate, but it rarely occurs when the mother's diabetes is controlled.

Prevention

Planning is the essential step to reduce the risk of birth defects and other pregnancy complications. If you're planning to get pregnant, tightly control your blood sugar for at least three to six months before conception -- as well as throughout your pregnancy. If you're taking oral diabetes medications, your doctor will help you replace them with insulin before you conceive. Preconception planning with your doctor and close follow-up throughout your pregnancy can help safeguard you and your baby against complications. Of course, discuss any changes to your diet, exercise or insulin plan in advance with your doctor.