Aging and Cancer: A Cancer 101 Adaptation to Educate Elders and Their Caregivers on the Importance of Cancer Screening and Early Detection 7th National Changing Patterns of Cancer in Native Communities: The Power of Partnerships Marie J. Lavigne, LMSW NCI’s Cancer Information Service - Northwest Region September 7, 2007 It is an honor to be with you today, to share a brief introduction to a Cancer 101 adaptation, “Aging and Cancer” which has been developed to educate elders and their caregivers about the importance of cancer screening and early detection, as well as to validate the needs, concerns and interests of elders receiving cancer care. My talk today will focus on presenting a brief overview of how to re-frame Cancer 101 for an audience of elders and their caregivers, by showing a “lens” of aging to articulate the key messages of this cancer education curriculum. As this session can be provided as a 3 hour, 90 minute or hour long presentation, in our brief time together I will focus on the what I believe are the most important changes made into the Cancer 101 curriculum in “Aging and Cancer” and focus on the Cancer Screening and Early Detection sections of Cancer 101. I have provided a copy of my slides for you to take with you and am willing to share all slides and resources on request.

Cancer 101 Learning Objectives Participants will learn why cancer is a growing concern for elder Alaskans by: Identifying the top five most commonly diagnosed cancers in Alaskans, Describing screening recommendations for cancer prevention and early detection, Discussing three or more factors contributing to improved cancer survival for elders, and Stating where to find the latest, most accurate information on cancer. As many elders and their caregivers may have limited knowledge and understanding about cancer, screening and early detection, the Cancer 101 curriculum, originally developed for American Indians/Alaska Natives by the NW Portland Area Indian Health Board in cooperation with Spirit of Eagles and support from NCI’s Cancer Information Service NW Region, offers an excellent educational framework to convey health information. I hope you are all familiar with Cancer 101 by now. I originally developed Aging and Cancer in partnership with the Alaska Geriatric Education Center as a tool for cancer education for Alaska’s growing elderly population. It was first presented at the GEC’s Summer Institute for “Best Practices in Elder Care” in June 2006. Aging and Cancer has been offered as a one hour, ninety minute and three hour presentation. It has been my experience that elders and their caregivers are receptive to presentations on cancer education designed to meet their needs and I continue to refine this presentation, to best meet the intended audience. As an adaptation of Cancer 101 for an elder/ caregiver audience, Aging and Cancer provide an opportunity to increase the audience’s knowledge and understanding about cancer, to lessen their fears and dispel myths about the disease, while encouraging screening and early detection of cancer. An added benefit of Aging and Cancer is the recognition of the value and importance of our elders health and well being.

Cancer is a Disease of Aging The risk of cancer increases with age. Close to 60% of all new cancers and 70% of deaths are in elders over 65. Increases in life expectancy means more older adults will experience cancer. Cancer is emerging as a chronic disease, rather than a terminal diagnosis. Advances in research and medical care have increased the length of time and quality of life of cancer survivors. As you are well aware, cancer is a disease of aging. Close to 60% of all new cancers and 70% of cancer deaths are in elders over 65. As the risk of developing cancer increases with age, screening and early detection are vitally important to reduce the cancer burden in the elderly. Yet in comparison with younger adult – as you will see in the cancer data slides ahead - those 65 years or older are far less likely to be screened for cancer, or to know the age and frequency recommended for screening, according to the Health Information National Trends Survey. There is a need for targeted cancer education for this audience, along with action to reduce barriers to screening and access to health care.

This slide, courtesy of my esteemed colleague Kate Landis at Southcentral Foundation and a founding member of the Alaska Breast and Cervical Health Partnership, illustrates beautifully the core message, that a woman’s risk of getting breast cancer increases with age. This also applies to other cancer types and to men’s cancer.

Cancer Burden in the Elderly Those diagnosed at age 60 or older compromise the majority of cancer survivors. Understanding elders needs and concerns is critical in reducing the cancer burden. Many older survivors have one or more chronic medical conditions that can mask the signs of cancer recurrence, or the late effects of cancer. Elders may live alone, or they may lack adequate social and caregiver support to support recovery. Limitations on Medicare reimbursement, along with out of pocket costs for treatment, medication and transportation, are a significant burden for those on fixed incomes. Source: The NCI Strategic Plan, January 2006 www.cancer.gov Before we go further, I want to put into context two national contributions to defining the cancer burden in the elderly. This is from the NCI Strategic Plan released in 2006, clearly stating that understanding elders needs and concerns is critical in reducing the cancer burden. Taking in mind the health, social, financial and support network surrounding an elder is critical to understanding their needs and the concerns of their family, caregivers and community in caring for them. .

Elders face unique cancer challenges Cancer survivors over age 65: Tend to be in poorer health (30% vs. 10% general population), Have two or more chronic conditions (12% vs. 5%), Experience greater functional limitations (60% vs. 30%), Are more likely to experience other serious illnesses: Alzheimer’s disease, arthritis, diabetes, previous cancers, heart-related diseases, strokes and hypertension. Experience lengthier hospitalizations and treatment complications, Face unique caregiver issues when their primary caregivers (spouses, older adult children) have serious health problems. Source: National Institute on Aging Cancer Survivorship: Pathways to Health After Treatment The National Institute on Aging, in its premier publication on the topic Cancer Survivorship: Pathways to Health After Treatment offers this assessment of the health needs of elders facing cancer.

Improved Cancer Longevity in Elders Potential factors include: Early detection Access to quality cancer care Compliance with recommended treatment Overall health status prior to cancer Nutrition and physical activity Family history and genetics Social support Beyond burdens and challenges, however, it is essential that we also understand what factors contribute to improved cancer longevity in elders. These also are very consistent with the findings of younger adult cancer survivors in their 30s, 40s and 50s.

Decreased Cancer Survival in the Elderly Potential factors include: Late detection and advanced stage of cancer Inability to comply with recommended treatment Difficulty accessing care Existing chronic health conditions Advanced age and frailty Genetic risk factors Type of cancer Conversely, factors contributing to decreased cancer survival are all to familiar to Alaska Natives and American Indian elders and their families.

Cancer Rates In Alaska Now I would like to walk you through several key slides, at a brisk pace, to give you a flavor for the Aging and Cancer curriculum as I have presented it in Alaska.

All Alaska Alaska Natives Cancer In Alaska All Alaska Alaska Natives Estimated New Cases in 2006 2,010 300 Estimated Cancer Deaths in 2006 810 134 Cancer Prevalence 21,000 * 2,325 ** Source: Cancer Facts and Figures, 2006 * Based on NCI estimates for US ** Alaska Native Tumor Registry

Five Leading Cancers Men and Women Combined Alaska Native Alaska White US White Colorectal 1. Prostate 1. Breast Lung 2. Breast 2. Prostate Breast 3. Lung 3. Lung Prostate 4. Colorectal 4. Colorectal Stomach 5. Bladder 5. Bladder Alaska Native Tumor Registry, 1999-2003 Alaska Cancer Registry, 1999-2002 US SEER, 1999-2002 http://seer.cancer.gov/

Age Distribution of Cancers in Alaska 1997-2001 Age at first diagnosis Ages 0-19 1% Ages 20-44 13% Ages 45-64 44% Ages 65 + 42% (n=9,652) 86% cancers are diagnosed in adults ages 45 and older Source: Alaska Cancer Registry

Age Specific Cancer Incidence Rates, Alaska Natives and US Whites This graph is a very quick visual to tell the story of changing demographics in Alaska as our population ages and cancer has emerged as a leading cause of death. Cancer was not a major cause of death in AN’s during the 1st part of the 20th century. For the most part, the main cause of death was infectious disease. In 1943, 43% of all Alaska Native deaths were due to tuberculosis. In the US, the overall cancer death rate declined throughout the 1990’s. In contrast, AN cancer death rates increased. Life expectancy for ANs has increased dramatically since 1950 when it was 47 years. In AN, 88% of cancers are diagnosed in patients 40 years or age and older. Aging of the population and increase in life expectancy contribute, in part, to the increase in the number of new cancer patients. Lifestyle changes, such as eating fewer traditional subsistence foods and more processed foods, along with an increase in smoking may also be contributing to the increase in more AN cancer patients. Source: AK Natives & Cancer – AK Native Tribal Health Consortium (Show Book) US White rates for years 1998-2002 Source: Alaska Native Tumor Registry

Five Leading Cancers By Age Alaska Natives, Men and Women Combined, 1989-2003 50-59 Years 60-69 Years 70+ Years Breast 21.0% Lung 23.0% Colorectal 25% Colorectal 19.5% Colorectal 19.1% Lung 22.4% Lung 15.6% Breast 11.9% Prostate 8.8% Oral 5.4% Prostate 8.8% Breast 7.4% Prostate 5.3% Stomach 5.0% Stomach 4.4% (n=789) (n=964) (n=1158) Source: Cancer in Alaska Natives, 1969-2003 Another way to present the data is to list leading cancers by ages, making note of the different leading cancers for elders in their 60s and 70s.

Cancer Risk By Age US Men and Women, All Races Age Cancer Risk 0-9 1 in 6,250 10-19 1 in 6,054 20-29 1 in 2,361 30-39 1 in 983 40-49 1 in 375 50-59 1 in 145 60-69 1 in 65 70+ 1 in 43 Source: NCI SEER Program Data, 1994-1998 Some audiences appreciate this risk by age, for others – especially lower literacy audiences – I would limit data slides such as this one.

Lifetime Probability of Developing Cancer - Men Site Risk All sites 1 in 2 Prostate 1 in 6 Lung and Bronchus 1 in 13 Colon and Rectum 1 in 17 Non-Hodgkin Lymphoma 1 in 46 Melanoma 1 in 52 Kidney 1 in 64 Leukemia 1 in 67 Oral Cavity 1 in 73 Stomach 1 in 82 2000-2002 Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan This slide and its companion for women’s cancers always generates discussion.

Lifetime Probability of Developing Cancer - Women Site Risk All sites 1 in 3 Breast 1 in 8 Lung and Bronchus 1 in 17 Colon and Rectum 1 in 18 Uterine Corpus 1 in 38 Non-Hodgkin Lymphoma 1 in 55 Ovary 1 in 68 Melanoma 1 in 77 Pancreas 1 in 79 Urinary Bladder 1 in 88 Uterine Cervix 1 in 135 2000-2002 Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

Age Distribution of Cancers Deaths in Alaska 1997-2001 Cancer Mortality (n=3,270) Ages 0-19 <1% Ages 20-44 7% Ages 45-64 35% Ages 65 + 58% 92% of cancers deaths are in adults over 45 Source: Alaska Cancer Registry While communities remember so vividly those who die very young from cancer, data from the Alaska Cancer Registry indicates 92% of cancers deaths are in adults over 45.

1,755 deaths combined, or 58% of all Alaska deaths in 2004 Deaths Due to Chronic Disease in Alaska Cancer is the leading cause of death in Alaska since 1993 1,755 deaths combined, or 58% of all Alaska deaths in 2004 Here’s a slide that helps to bring the cancer data into the context of chronic disease deaths across Alaska, * Any mention Source: Alaska Bureau of Vital Statistics

Reducing Your Cancer Risk Elders and their caregivers, when approaches as educators for our young people and invested in their own health, are surprisingly receptive to information on reducing their cancer risk and prevention.

Leading Causes of Cancer This is a popular slide our Cancer Program uses, to talk about risk factors and behavioral/ lifestyle choices. Its one way to being the tobacco and nutrition message home. The exact causes of cancer are not known. Although, the more we learn about what causes cancer, the more likely we are to find ways to prevent it. Cancer develops over time. It is a result of a complex mix of factors related to lifestyle, heredity and environment. Risk factors are conditions that increase the chance that cancer might occur. Because cancer usually requires a number of mutations, the chances of developing cancer increase as a person gets older because more time has been available for mutations to accumulate. For example, a person 75 years old is a thousand times more likely to develop and die of colon cancer than a person 25 years old. Because people are living longer today than they did 50 or 100 years ago, they have a longer exposure time to the factors that may start gene changes that lead to cancer. Some cancer risk factors can be controlled such as smoking, eating habits and exercising. Some risk factors can’t be controlled such as age, and family history of cancer. It’s important to note that some people with several risk factors never develop cancer, while others with no known risk factors do develop cancer. Source: The Harvard Report on Cancer Prevention

Reducing Your Cancer Risk Research is ongoing and early findings suggest healthy lifestyles may reduce your cancer risk: A diet rich in natural foods, fruits and vegetables, Maintain a healthy weight, Daily physical activity, Abstain from tobacco use, Moderate alcohol use, Limit sun exposure, Avoid known carcinogens, Protect yourself and your partner from sexually transmitted diseases, Screening and early detection for cancer. Here’s another way, to talk about what a healthy lifestyle is. It’s a great discussion point for audience dialogue. We know that by reducing exposure to cancer-causing agents such as tobacco, and by promoting healthy nutrition and physical activity, we can reduce the risk of developing some cancers. Ways to reduce the cancer burden include: Education Personal action to reduce cancer risk Routine screening for early detection Cancer survival can also be improved by screening and early detection, especially for cancers of the cervix, colon, rectum and breast. For other types of cancer, such as the lung, no reliable screening test exists. The majority of lung cancers are preventable by simply avoiding tobacco. It is estimated that nearly two-thirds of cancer deaths in the US can be linked to tobacco use, diet, and lack of exercise.

What Is Cancer? I am hoping all these Cancer 101 Slides will look familiar, and will walk very quickly through them to offer a quick overview for those who may not have attended a Cancer 101 session before.

What is Cancer? Cancer is a disease characterized by: A series of changes in the cells and genes leading to abnormal cell proliferation (growth). Unchecked local growth (tumor formation) and invasion of surrounding tissue. Ability to spread (metastasize). The term cancer refers to a group of more than 100 different diseases that begin in cells, the body’s basic unit of life.

How cancer cells develop Cancer develops when changes occur within cells that effect the DNA. DNA contains genes that are programmed to perform specific tasks. Changes or “mutations” in the DNA lead to the development of cancer. DNA Structure Genes reside within large DNA molecules, which are composed of two chemical strands twisted around each other to form a "double helix." Each strand is constructed from millions of chemical building blocks called "bases." DNA contains only four different bases (abbreviated A, T, G, and C), but they can be arranged in any sequence. The sequential order of the bases in any given gene determines the message the gene contains, just as the letters of the alphabet can be combined in different ways to form distinct words and sentences. Genes can be mutated in several different ways. The simplest type of mutation involves a change in a single base along the base sequence of a particular gene—much like a typographical error in a word that has been misspelled. In other cases, one or more bases may be added or deleted. And sometimes, large segments of a DNA molecule are accidentally repeated, deleted, or moved Gene Mutations and Cancer Mutations in genes that control normal cell proliferation can lead to cancer. These mutations can be created by DNA-damaging carcinogens such as cigarette by-products and radiation. However, some cancer-causing mutations are simply spontaneous errors that appear in normal DNA molecules when cells duplicate their DNA prior to cell division. The mutations that contribute to the development of cancer affect three general classes of gene: oncogenes, tumor suppressor genes, and DNA repair genes. Cancer Tends to Involve Multiple Mutations Cancer often arises because of the accumulation of mutations involving oncogenes, tumor suppressor genes, and DNA repair genes. For example, colon cancer can begin with a defect in a tumor suppressor gene that allows excessive cell proliferation. The proliferating cells then tend to acquire subsequent mutations involving a DNA repair gene, an oncogene, and several other tumor suppressor genes. The accumulated damage yields a highly malignant, metastatic tumor. In other words, creating a cancer cell requires that the brakes on cell growth (tumor suppressor genes) be released at the same time that the accelerators for cell growth (oncogenes) are being activated.

Abnormal Cell Growth: Increasing number of dividing cells  Growing mass of tissues (Tumor)   Benign Malignant

Benign vs Malignant Tumors The gradual increase in the number of dividing cells creates growing mass of tissue called a “tumor.” Tumors can be benign (non-cancerous) or malignant (cancer). Benign tumors do not spread to other parts of the body, are usually not a threat to life and are labeled by adding the suffix –oma to the tissue of origin (e.g. lipoma, adenoma) Malignant tumors are cancerous cells that grow without control and invade or damage other parts of the body. Malignant versus Benign Tumors Depending on whether or not they can spread by invasion and metastasis, tumors are classified as being either benign or malignant. Benign tumors are tumors that cannot spread by invasion or metastasis; hence, they only grow locally. Malignant tumors are tumors that are capable of spreading by invasion and metastasis. By definition, the term "cancer" applies only to malignant tumors lipoma: benign tumor composed of lipid cells. adenoma: benign tumor composed of glandular cells.

When Cancer Spreads Metastasis is the spread of a malignant tumor from its primary (original) site to another part of the body. Cancer cells may spread by blood capillaries and veins (most common route), seeding throughout body, or the lymphatic system. The most common sites are: Bone Lung Liver Central nervous system Seeding – body cavity (peritoneal) Lymph system Blood vessel – migration of metas. Cells to the periphery of the primary tumor, penetration of the extracellular matrix of the tumor by enzymes and other factors, penetration of surrounding blood vessel walls, dissemination in to the bloodstream, Interaction with host factors (platelets, lymphocytes, formation of clusters or emboli, adherence to blood vessel walls in distant organ localized growth stimulated by growth factors extravasation out of blood vessel in to adjacent tissue proliferation of the metastatic deposit of cells, formation of a supporting vascular system via angiogenesis (secretion of TAF). Metastasis is a major cause of death from cancer.

Metastasis: How cancer spreads If melanoma, a type of skin cancer, metastasizes (spreads) to the liver, the cancer cells in the liver are melanoma cells. The disease is called metastatic melanoma (not liver cancer).

Screening & Early Detection

The Importance of Cancer Screening Checking for cancer in a person who does not have symptoms of the disease is called screening. The goal of screening is to improve outcomes – to reduce cancer deaths and enhance quality of life. Cancer survival can be improved by screening and early detection for cancers of the breast, cervix, colon and rectum. For other types of cancer, such as the lung, no reliable screening test currently exists. The key messages about cancer screening are the same here as in other Cancer 101 presentations: The sooner cancer is detected and treated, the better an elder’s chance for full recovery. The goal of screening is to improve outcomes – to reduce cancer deaths and enhance quality of life.

Cancer Early Detection The chances cancer will be detected early are greatly improved by having regular health check ups and being aware of changes in your body. During a physical exam, the provider will look for anything unusual, feel for lumps or growths, inquire about any cancer warning signs you may be experiencing, recommend tests needed and answer your questions. The goal is to discover a cancerous tumor early before it grows and spreads. This is also an important message for elders to receive and understand about early detection and the benefits of early treatment. Cancer Early Detection The provider will take into account the person’s age, medical history, general health, family history and lifestyle. This information informs the provider in determining a person’s risk for developing cancer and what tests to recommend.

Possible Symptoms of Cancer: Pay Attention To Your Body If There Is: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening, lump, or swelling in the breast or any other part of the body Indigestion or difficulty swallowing Recent change in wart or mole Nagging cough or hoarseness … along with unexplained weight loss, fever, fatigue and pain that is present for several weeks or longer. This slide, which uses ACS’s 7 Possible Signs of Cancer, is a wonderful reminder for audience members of paying attention to changes in their body that may indicate warning signs of cancer. These 7 factors are presented as common warning signs of cancer… yet audiences are encouraged to keep in mind that: Cancer can be caused by a variety of symptoms, These are some of them. When these symptoms or other symptoms occur, they are NOT always caused by cancer. They may also be caused by infections, benign tumors, or other problems. Early cancer usually does not cause pain! It is important to see a health care provider about any of these symptoms or other physical changes. Only a health care provider can make a diagnosis.

Screening Rates in Older Alaskans For an audience with providers and/or caregivers with a higher level of education, I would also include these slides… on screening rates.

Screening Rates in Older Adults Older women having pap tests within past three years: Alaska US Ages 55-64 * 86.1% 87.8% Ages 65+ N/A 69.9% Older women having mammography within past two years: Ages 50-59 * 76.5% 79.7% Ages 60-64 * N/A 80.0% Ages 65+ 67.8% 75.1% Source: Behavioral Risk Factor Surveillance System, 2004 * The Alaska Breast & Cervical Health Check offers free health screenings for women ages 18-64 The Alaska Breast & Cervical Health Check offers free health screenings for women ages 18-64 who are uninsured or there insurance does not cover a clinical breast exam, mammography, pelvic exam and pap test. Income guidelines apply. For more information: 644-9620 (Anchorage) or 1-800-410-MAMM (6266).

Screening Rates in Older Adults Older men and women ever having a sigmoidoscopy or colonoscopy for colorectal cancer screening: Alaska US Ages 50-59 41.8% 42.3% Ages 60-64 N/A 55.7% Ages 65+ 69.6% 63.2% Source: Behavioral Risk Factor Surveillance System, 2004

Barriers to Cancer Screening and Early Detection in Elders Fear of cancer Lack of knowledge Modesty Communication Illness beliefs Access This information may be presented to a provider audience, or shared in a general way to talk about common elder concerns. Making Informed Decisions About Screening Elders need to discuss their questions and concerns about cancer screening with their health care provider. Considerations Medical, environmental, lifestyle, and genetic factors are known to affect the chance of developing cancer and may affect the need and frequency for screening. Decisions about screening May be affected by personal risk factors, potential benefits and harms, the values and judgments of patients and their health care providers. Evidence is often not clear-cut. In many cases, experts' opinions about appropriate cancer screening may differ, especially regarding which procedures they recommend, at what age, what interval, and as new evidence becomes available.

Breast Cancer Screening

Breast Cancer Screening Screening for breast cancer has been shown to reduce the risk of dying from the disease. A high quality mammogram with a clinical breast exam is the most effective way to detect breast cancer early. NCI recommends women in their 40s and older should have mammograms every 1 to 2 years. Women at higher than average risk should talk with their health care providers about how often to be screened. Screening mammogram is an x-ray of the breast used to detect breast changes in women who have no symptoms of breast cancer. It usually involves two x-rays of each breast. With a mammogram, it is possible to detect microcalcifications (tiny deposits of calcium in the breast, which sometimes are a clue to the presence of breast cancer) or a tumor that cannot be felt. A high quality mammogram with a clinical breast exam is the most effective way to detect breast cancer early. Diagnostic mammogram is an x-ray of the breast used to diagnose unusual breast changes such as a lump, pain, thickening, nipple discharge, or a change in breast size or shape. It involves more x-rays than a screening mammogram to obtain views of the breast from several angles. The technician may magnify a suspicious area to produce a detailed picture that can help the health care provider make an accurate diagnosis. Breast Self Exams Studies have not shown checking one’s own breasts for lumps or unusual changes - alone – does not reduce the number of deaths from breast cancer. Self exams should not take the place of a clinical breast exam with a mammogram, which can detect breast cancer that cannot be felt. Benefit of screening mammograms Several large studies conducted around the world show that breast cancer screening with mammograms reduces the number of deaths from breast cancer for women ages 40 to 69, especially those over age 50.

Who Is At Risk for Breast Cancer? Age - most important risk factor for breast cancer. Personal history of breast cancer Family history Genetic alterations Certain breast changes on biopsy Reproductive and menstrual history: Age of first childbirth Early menses or late menopause No childbirth experience Hormone Therapy Breast density Diet and lifestyle factors Radiation therapy The risk of breast cancer increases gradually as a woman ages. Personal history of breast cancer Women who have had breast cancer are more likely to develop a second breast cancer. Family history A woman’s chance of developing breast cancer increases if her mother, sister, and/or daughter had breast cancer. Genetic alterations in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. These alterations are rare and are estimated to account for less than 10% of all breast cancers. Certain breast changes on biopsy A diagnosis of atypical hyperplasia (a non-cancerous condition in which cells have abnormal features and are increased in number) or lobular carcinoma in situ (LCIS) (abnormal cells found in the lobules of the breast) increases a woman’s cancer risk. Reproductive and menstrual history. Evidence indicates that: Age of first childbirth The older a woman is when she has her first child, the greater her chance of developing breast cancer. Early menses or late menopause Women who started menstruating at an early age (age 11 or younger), experienced menopause late (after age 55) are at an increased risk. No childbirth experience Women who have never had children are also at an increased risk of developing breast cancer. Hormone Therapy Women who take hormone replacement therapy for a long time appear to have an increased chance of developing breast cancer. Breast density As breast cancers nearly always develop in the dense tissue of the breast (not in the fatty tissue), older women who have mostly dense tissue are at an increased risk of breast cancer. Abnormalities in dense breasts are also more difficult to detect on a mammogram. Diet and lifestyle factors Diet is thought to play a role in breast cancer risk, although researchers have not yet identified specific dietary factors that affect risk. Differences in diet may explain the lower risk of breast cancer among Asian women compared with American women. Studies have found obesity and weight gain in postmenopausal women increase breast cancer risk. A number of studies suggest that moderate alcohol consumption may also increase a woman’s chance of developing breast cancer. Radiation therapy (“x-ray therapy”) Women who had radiation therapy to the chest (including the breasts) before age 30 are at an increased risk of developing breast cancer throughout their lives.

Breast Cancer Screening and Medicare In women ages 65 and older, 68% report having had a mammogram in the prior two years. Medicare currently covers an annual screening mammogram for all eligible women over 40. A physician’s referral is not required. There is no Part B deductible, however a 20% co-insurance or co-payment applies. Source: Federal Interagency Forum on Age Related Statistics CMS Medicare utilization, accessed May 31, 2006 http://www.medicare.gov/

Cervical Cancer Screening

Cervical Cancer Screening It is recommended women of average risk have a Pap test at least once every three years. Women 65-70 years of age who have had at least three normal Pap tests and no abnormal tests in the last 10 years may decide, upon consultation with their health care provider, to stop cervical screening. Women who have had a total hysterectomy do not need to undergo cervical cancer screening, unless the surgery was done to treat cervical cancer. Source: U.S. Preventative Services Task Force Based on good evidence, regular screening of appropriate women for cervical cancer with the Papanicolaou (Pap) test reduces mortality from cervical cancer. Since the 1930s, early detection using the Pap test has helped lower the death rate from cervical cancer more than 75 percent. The Pap test (sometimes called a Pap smear) is a way to examine cells collected from the cervix (the lower, narrow end of the uterus). The main purpose of the Pap test is to find abnormal cell changes that may arise from cervical cancer or before cancer develops. In a pelvic exam, the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum are felt to find any abnormality in their shape or size. During a pelvic exam, an instrument called a speculum is used to widen the vagina so that the upper portion of the vagina and the cervix can be seen. A Pap test and pelvic exam are important parts of a woman’s routine health care because they can detect cancer or abnormalities that may lead to cancer of the cervix If the Pap test shows abnormalities, further tests and/or treatment may be necessary Human papillomavirus (HPV) infection is the primary risk factor for cervical cancer

Common Cervical Cancer Questions Could I have cervical cancer and not know it? YES--often cervical cancer does not cause pain or other symptoms. If I've gone through menopause, do I still need a Pap test? Most women still need to Pap tests. This decision depends on your age and past results. Talk with your health care provider about what’s right for you. If I'm not sexually active now do I still need a Pap test? Women who are not currently sexually active may still need a Pap test. Almost all cervical cancer is caused by a sexually transmitted virus called the (HPV) Human Papillomavirus that can live in the body for many years. What is a Pap test? A Pap test finds problems that can be treated before they turn into cervical cancer. A Pap test also can find cancer early. If cervical cancer is found early, it's easier to cure. Could I have cervical cancer and not know it? YES--often cervical cancer does not cause pain or other symptoms. How often should I get a Pap test? You should have a Pap test at least once every 3 years. If you are age 65 or older, talk with your doctor about whether you still need to get Pap tests. You and your doctor can decide what testing schedule is right for you based on your past Pap test results. A Pap test is important to me because it can: Find abnormal cervical cell changes before they have a chance to become cancerous. Tell if you have cervical cancer early - while it's easier to cure. If I've had a hysterectomy, do I still need a Pap test? After a hysterectomy, you still need to get Pap tests if: You had a partial hysterectomy (an operation that removed the uterus but not the cervix) You had a total hysterectomy (an operation that removed both the uterus and the cervix) to treat cervical cancer or a condition that might lead to cancer You may not need to get Pap tests if you have had a total hysterectomy for other reasons (e.g., fibroids). Talk with your health care provider about what is right for you.

Cervical Cancer Screening and Medicare High Risk – Annual Screening Medicare covers one Pap test and pelvic exam for women at high risk for cervical cancer, including those with an abnormal pap during the prior three years. Low Risk – Every Two Years Medicare covers one Pap test and pelvic exam every two years for women at low cancer risk. Breast Exam - A clinical breast exam is included as part of the Medicare pelvic screening benefit. There is no Part B deductible and no cost for the Pap lab test, however a 20% co-payment applies for the pelvic and breast exams. Source: CMS Medicare http://www.medicare.gov/

Colorectal Cancer Screening Colorectal cancer screening is used to detect cancer, precancerous polyps, or other abnormal conditions. If screening detects an abnormality, diagnosis and treatment can occur promptly. In addition, finding and treating polyps may be one of the most effective ways to prevent the development of cancer altogether. Colorectal cancer is generally more treatable when found early. Several major organizations, including the U.S. Preventive Services Task Force (a group of experts convened by the U.S. Public Health Service), the American Cancer Society, and professional societies, have developed guidelines for colorectal cancer screening. Although some details of their recommendations vary regarding which screening tests to use and how often to be screened, all of these organizations support screening for colorectal cancer. People should talk with their health care provider about when to begin screening for colorectal cancer, what tests to have, the benefits and risks of each test, and how often to schedule appointments. The decision to have a certain screening test will take into account several factors: Person’s age, medical and family history, general health; Accuracy of the test; Risks associated with the test; Preparation required before the test; Sedation necessary during the test; Follow-up care after the test; Convenience of the test; and Cost and insurance coverage of the test.

Colorectal Cancer Screening To find polyps or early colorectal cancer, adults of average risk in their 50s and older should be screened. A health care provider may recommend one or more of the following tests, based on age, family history and risk factors: Sigmoidoscopy Colonoscopy Fecal Occult Blood Test (FOBT) Double Contrast Barium Enema (DCBE) Digital Rectal Exam (DRE) Colorectal cancer screening is used to detect cancer, precancerous polyps, or other abnormal conditions. If screening detects an abnormality, diagnosis and treatment can occur promptly. In addition, finding and treating polyps may be one of the most effective ways to prevent the development of cancer altogether. Colorectal cancer is generally more treatable when it is found early. Sigmoidoscopy is an examination of the rectum and lower colon using a lighted instrument called a sigmoidoscope. Sigmoidoscopy can find precancerous or cancerous growths in the rectum and lower colon. Studies suggest regular screening by sigmoidoscopy after age 50 can reduce the number of colorectal cancer deaths. A screening sigmoidoscopy is typically performed every 5 years. Colonoscopy is an examination of the rectum and entire colon using a lighted instrument called a colonoscope. Colonoscopy can find precancerous or cancerous growths throughout the colon, including the upper colon that is not screened by a sigmoidoscopy. Due to risks of bleeding and puncturing of the lining of the colon, it is not known whether this benefit outweighs the risks of colonoscopy. More research is underway. A screening colonoscopy is typically performed every 10 years. Fecal occult blood test (FOBT) checks for hidden blood in the stool. Studies have proven that this test, when performed every 1 to 2 years in people ages 50 to 80, reduces the number of deaths due to colorectal cancer by as much as 30 percent. Double contrast barium enema (DCBE) is a series of x-rays of the entire colon and rectum. The x-rays are taken after the patient is given an enema with a barium solution and air is introduced into the colon. The barium and air help to outline the colon and rectum on the x-rays. Research shows that DCBE may miss small polyps. Digital rectal exam (DRE) is often part of a routine physical examination. The health care provider inserts a lubricated, gloved finger into the rectum to feel for abnormal areas. DRE allows for examination of only the lower part of the rectum.

Colorectal Cancer Screening The optimal interval for screening depends on the test and the provider’s assessment of cancer risk. For the person at average risk, initial screening begins at age 50 and includes: Annual FOBT with a Colonoscopy every 10 years, or Annual FOBT with a Flexible Sigmoidoscopy every 5 years. For individuals at high risk, screening needs to begin earlier and take place more often. Source: U.S. Preventative Services Task Force Scientists are still studying colorectal cancer screening methods, both alone and in combination, to determine how effective they are. Studies are also under way to clarify the risks of each test. New tests for colorectal cancer screening are under study. For example, virtual colonoscopy (also called computed tomographic colonography) is a procedure that uses special x-ray equipment to produce pictures of the colon. A computer then assembles these pictures into detailed images that can show polyps and other abnormalities. Because it is less invasive and does not require sedation, virtual colonoscopy may cause less discomfort and take less time than conventional colonoscopy. However, as with conventional colonoscopy and DCBE, thorough preparation of the colon is necessary before the test. Unlike conventional colonoscopy, it is not possible to remove polyps or perform a biopsy during virtual colonoscopy. An additional procedure, such as conventional colonoscopy, is needed if the virtual procedure finds a potential problem. Clinical trials (research studies with people) are under way to compare the advantages and disadvantages of virtual colonoscopy with those of other colorectal cancer screening tests.

Who Is At Risk for Colorectal Cancer? Certain risk factors are associated with an increased risk of developing colorectal cancer: Age Polyps Family history Familial Adenomatous Polyposis (FAP) Nutrition Physical activity Ulcerative colitis or Crohn’s colitis The exact causes of colorectal cancer are not known. However, research indicates certain risk factors are linked to an increased risk of developing colorectal cancer and influence decisions about when and how often to screen for colorectal cancer: Age Most people who develop colorectal cancer are over age of 50. Polyps are growths that protrude from the inner wall of the colon or rectum. They are relatively common in people over age 50. Most polyps are benign (non-cancerous); however, experts believe that most colorectal cancers develop in certain polyps, called adenomas. Therefore, detecting and removing these growths may help prevent cancer. The procedure to remove polyps is called a polypectomy. Family history Close relatives (parents, siblings, or children) of a person who has had colorectal cancer are more likely to develop this type of cancer, especially if the family member developed the cancer at a young age. If many family members have had colorectal cancer, the chances increase even more. Screening may begin sooner in persons with a family history of early colorectal cancer. Familial Adenomatous Polyposis (FAP) is a rare, inherited condition in which hundreds of polyps develop in the colon and rectum. Nutrition Some evidence suggests that the development of colorectal cancer may be associated with a diet that is high in fat and calories and low in foods with fiber, such as whole grains, fruits, and vegetables. Researchers are exploring what role these and other dietary components play in the development of colorectal cancer. Physical Activity Some evidence suggests a sedentary lifestyle may be associated with an increased risk of colorectal cancer. People who exercise regularly may have a decreased risk of developing colorectal cancer. Ulcerative colitis or Crohn’s colitis People with these conditions are more likely to develop colorectal cancer.

Colorectal Cancer Screening and Medicare Medicare coverage for colorectal cancer screening tests is based on the U.S. Preventative Services Task Force recommendations. Despite coverage, Medicare claims suggest only 31% beneficiaries ever had a colorectal cancer screening test (1998-2002). The Medicare deductible and coinsurance apply to this benefit. For screenings performed on an outpatient basis, the beneficiary is responsible for 20% of the approved Medicare amount. Source: Federal Interagency Forum on Age Related Statistics CMS Medicare utilization, accessed May 31, 2006 http://www.medicare.gov What Medicare Covers Medicare covers various screening tests to help find colorectal cancer itself or identify and remove precancerous polyps (growths in the colon).  Coverage for these tests varies based on a beneficiary's risk for colorectal cancer.  A beneficiary is considered to be at high risk if he or she has any of the following risk factors: (See USPSTF Guidelines for Risk Factors) Fecal occult blood test (FOBT) - This test checks for occult or hidden blood in the stool.  A health care provider gives a fecal occult blood test card to the beneficiary, who takes it home and places stool samples on it.  The beneficiary either returns the card with the stool samples to the health care provider or to a laboratory for testing.  Medicare covers one screening FOBT annually for beneficiaries aged 50 and older.  A written order from the physician responsible for using the results of the test in the management of the beneficiary's medical condition is required for Medicare coverage of this test. The deductible and coinsurance do not apply to this test. Flexible sigmoidoscopy - In this procedure, the provider inserts a short, thin, flexible, lighted tube into the rectum to check for polyps or cancer in the rectum and lower third of the colon.  A beneficiary may also receive a fecal occult blood test in combination with this procedure.  For beneficiaries ages 50 and older at high risk for colorectal cancer, Medicare covers 1 screening flexible sigmoidoscopy every 4 years.  For beneficiaries ages 50 and older not at high risk for colorectal cancer, Medicare also covers 1 flexible sigmoidoscopy every 4 years.  However, if a beneficiary who is not at high risk has had a colonoscopy in the preceeding 10 years, then Medicare will not pay for a screening flexible sigmoidoscopy until 119 months have passed from this last colonoscopy.  A doctor of medicine or osteopathy must order this screening test.  The Medicare deductible and coinsurance apply to this benefit.  For screenings performed in an outpatient hospital department, the beneficiary is responsible for 20% of the Medicare approved amount. Colonoscopy - In this procedure, the provider inserts a longer, thin, flexible, lighted tube into the rectum to check for polyps or cancer in the rectum and the entire colon.  Most polyps and some cancers can be found and removed during this procedure, which is considered the "gold standard" test for colorectal cancer screening.  Medicare provides coverage for 1 colonoscopy every 2 years for high risk beneficiaries regardless of age. Medicare covers 1 colonoscopy every 10 years for beneficiaries not at high risk, but not within 47 months of a screening flexible sigmoidoscopy.  A doctor of medicine or osteopathy must order this screening test.  The Medicare deductible and coinsurance apply to this benefit.  For screenings performed in an outpatient hospital department, the beneficiary is responsible for 20% of the Medicare approved amount.  Beneficiaries are not liable for the costs of this procedure when performed at a critical access hospital. Barium enema - In this procedure, the beneficiary is given an enema with barium.  X-rays are taken of the colon, which allow the provider to see the outline of the colon and to check for polyps or other abnormalities.  Medicare covers this screening test as an alternative to a flexible sigmoidoscopy, or a high risk screening colonoscopy.  For beneficiaries at high risk for colorectal cancer, Medicare covers 1 screening barium enema procedure every 2 years, regardless of age.  For beneficiaries not considered high risk and who are ages 50 and older, Medicare covers 1 screening barium enema procedure every 4 years.  A doctor of medicine or osteopathy must order this screening test in writing and justify why this test is an appropriate alternative for the beneficiary.  The Medicare deductible and coinsurance apply to this benefit.  Beneficiaries are not liable for the costs of this procedure when performed at a critical access hospital.

Prostate Cancer Screening The evidence is insufficient to determine whether screening for prostate cancer with prostate-specific antigen (PSA) or digital rectal exam (DRE) reduces mortality from prostate cancer. Screening tests are able to detect prostate cancer at an early stage, but it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the natural history and outcome of the disease. Ecological evidence shows a trend toward lower mortality for prostate cancer in some countries, but the relationship between these trends and intensity of screening is not clear and associations with screening patterns are inconsistent. The observed trends may be due to screening, or to other factors such as improved treatment. Neither of the screening tests for prostate cancer is perfect. Most men with mildly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal levels of PSA. Also, the DRE can miss many prostate cancers. The DRE and PSA test together are better than either test alone in detecting prostate cancer.

Prostate Cancer Screening There are two prostate screening to detect abnormalities: Digital Rectal Examination (DRE) Prostate Specific Antigen Test (PSA) These tests can indicate abnormalities, but cannot show if they are due to cancer or another, less serious condition. Men should discuss prostate cancer screening with their health care providers and together weigh the potential benefits and harms of screening and follow-up procedures. Tests that may detect prostate cancer are being studied: Digital rectal exam is an exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum to feel the prostate for lumps or anything else that seems unusual. Prostate-specific antigen test test is a test that measures the level of PSA in the blood. PSA is a substance made mostly by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. PSA levels may also be high in men who have an infection or inflammation of the prostate or benign prostatic hyperplasia (BPH; an enlarged, but noncancerous, prostate). Scientists at the National Cancer Institute are studying the combination of PSA testing and digital rectal exam as a way to get more accurate results from the screening tests. Available evidence on the benefits and harms of prostate cancer screening is not clear-cut. Experts' opinions about the appropriateness of screening differ, especially regarding whether to screen and which procedures to recommend, at what age and at what interval. Men should discuss prostate cancer screening with their health care providers and together weigh the potential benefits and harms of screening and follow-up procedures.

Prostate Cancer Screening and Medicare Medicare coverage includes the Prostate Specific Antigen (PSA) blood test and a digital rectal exam. An annual digital rectal examination and PSA test is covered every 12 months, beginning at age 50. Generally, you pay 20% of the Medicare approved amount for the exam after the yearly Part B deductible. There is no co-insurance and no Part B deductible for the PSA test. Source: CMS Medicare http://www.medicare.gov/ Available evidence on the benefits and harms of prostate cancer screening is not clear-cut. Experts' opinions about the appropriateness of screening differ, especially regarding whether to screen and which procedures to recommend, at what age and at what interval. Men should discuss prostate cancer screening with their health care providers and together weigh the potential benefits and harms of screening and follow-up procedures. ACS recommendations for men 50+ and 45+ if family history and/or African-American digital rectal exam and/or prostate specific antigen (PSA) blood test Although it is not certain that screening for other cancers actually saves lives, doctors may also suggest screening for cancers of the skin, lung, and oral cavity. Doctors may also offer to screen men for testicular cancer and women for ovarian cancer.It is important for people may want to discuss any concerns or questions they have about screening with their doctors, so they can weigh the pros and cons and make informed decisions about having screening tests.

Cancer Diagnosis Adding time for cancer diagnosis and treatment slides will require that you offer lots of time for questions – and ideally, have a health care provider present to help answer questions if you are not able to. Again, you will see the Cancer 101 slides as originally designed presented here.

Cancer Diagnosis Diagnosis of Cancer To diagnose the presence of cancer requires looking under a microscope at a sample of the affected tissue and the appearance of the cells to determine if it is benign (non-cancerous) or malignant (cancerous), the type of cancer (eg. sarcoma vs. carcinoma) and its “aggressiveness.” Tissue can be removed for biopsy by: endoscopy needle biopsy surgical biopsy. Microscopic Appearance of Cancer Cells Cancer tissue has a distinctive appearance under the microscope. Among the traits the doctor looks for are a large number of dividing cells, variation in nuclear size and shape, variation in cell size and shape, loss of specialized cell features, loss of normal tissue organization, and a poorly defined tumor boundary. Biopsy To diagnose the presence of cancer, a doctor must look at a sample of the affected tissue under the microscope. Hence, when preliminary symptoms, Pap test, mammogram, PSA test, or fecal occult blood test indicate the possible existence of cancer, a doctor must then perform a biopsy, which is the surgical removal of a small piece of tissue for microscopic examination. (For leukemias, a small blood sample serves the same purpose.) Microscopic examination will tell the doctor whether a tumor is actually present and, if so, whether it is malignant (i.e., cancer) or benign. Punch biopsy (removal of tissue from the core of the tumor) shave biopsy Bone marrow biopsy , spinal tap Surgical - incisional (part) excisional (whole tumor) Anesthesia (local and or general)

Types of Cancer Carcinomas Sarcomas Lymphomas Leukemia Myelomas Five main groups of cancers: Carcinomas Sarcomas Lymphomas Leukemia Myelomas Treatment decisions are based on knowing the type of cancer involved. Carcinomas: Cancers that begin in epithelial tissues - Adenocarcinomas Arise from glandular epithelium (Pancreatic adenocarcinoma) - Squamous cell carcinoma Arise from squamous epithelium (Squamous cell carcinoma of the skin) Sarcomas: Cancers that start in connective tissue: Osteo - bone Chondro - cartilage Lipo - fat Rhabdo - skeletal muscle Leiomyo - smooth muscle Lymphomas: Cancers of the lymphoid tissues (Hodgkin’s or Non-Hodgkin’s lymphoma) Leukemias: Cancers of the blood cells and lymphatic tissues most commonly involve the white blood cells. Myelomas: Cancers of the plasma cells found in the bone marrow. Including lymphocytes and lymph nodes

Determining the Stage of Cancer Diagnosis of Cancer Determining the Stage of Cancer Once the diagnosis of cancer is made, knowing the “stage” of the disease tells how far the disease has spread and can inform treatment decisions. In situ Early cancer that hasn’t spread Local Cancer found only in the organ where it started to grow Regional Cancer that has spread to surrounding tissues and lymph nodes Distant Cancer that has spread to other organs and systems of the body A multi-disciplinary team approach is used to determine the stage of the cancer and includes review of patient history, physical examination, radiological examination and laboratory data. Tumor Staging After cancer has been diagnosed, doctors ask the following three questions to determine how far the disease has progressed: 1. How large is the tumor, and how far has it invaded into surrounding tissues? 2. Have cancer cells spread to regional lymph nodes? 3. Has the cancer spread (metastasized) to other regions of the body? Based on the answers to these questions, the cancer is assigned a "stage." A patient's chances for survival are better when cancer is detected at a lower stage number

Cancer Stages Diagnosis of Cancer Staging describes the extent or severity of cancer. Knowing the stage helps to plan treatments and estimate prognosis. Most cancers can be described as follows: Stage 1 A cancerous tumor is found to be limited to the organ of origin. Stage 2 Cancer has spread to surrounding tissues and possibly local lymph nodes. Stage 3 There is extensive growth of the primary tumor and it is possible there are other organs involved. Stage 4 The cancer has spread far into the other organs and systems of the body. Each cancer is different. Staging can provide information used in determining prognosis and influencing treatment recommendations. Staging describes the extent or severity of an individual’s cancer. Knowing the stage of the disease helps the doctor plan a person’s treatment and estimate prognosis . Staging systems for cancer have evolved over time and continue to change as scientists learn more about cancer. The TNM staging system is based on the extent of the tumor (T), spread to lymph nodes (N), and metastasis (spread to other parts of the body) (M). Most cancers can be described as stage 0, stage I, stage II, stage III, or stage IV. Physical exams, imaging procedures, laboratory tests, pathology reports, and surgical reports provide information to determine the stage of the cancer (see Question 6).

Cancer Treatment How Does Chemotherapy Work? Normal cells grow and die in a controlled way. When cancer occurs, cells in the body that are not normal keep dividing and forming more cells without control. Anticancer drugs destroy cancer cells by stopping them from growing or multiplying. Healthy cells can also be harmed, especially those that divide quickly. Harm to healthy cells is what causes side effects. These cells usually repair themselves after chemotherapy. Because some drugs work better together than alone, two or more drugs are often given at the same time. This is called combination chemotherapy. Other types of drugs may be used to treat your cancer. These may include certain drugs that can block the effect of your body's hormones. Or doctors may use biological therapy, which is treatment with substances that boost the body's own immune system against cancer. Your body usually makes these substances in small amounts to fight cancer and other diseases. These substances can be made in the laboratory and given to patients to destroy cancer cells or change the way the body reacts to a tumor. They may also help the body repair or make new cells destroyed by chemotherapy. What Can Chemotherapy Do? Depending on the type of cancer and how advanced it is, chemotherapy can be used for different goals: To cure the cancer. Cancer is considered cured when the patient remains free of evidence of cancer cells. To control the cancer. This is done by keeping the cancer from spreading; slowing the cancer's growth; and killing cancer cells that may have spread to other parts of the body from the original tumor. To relieve symptoms that the cancer may cause. Relieving symptoms such as pain can help patients live more comfortably. Is Chemotherapy Used With Other Treatments? Sometimes chemotherapy is the only treatment a patient receives. More often, however, chemotherapy is used in addition to surgery, radiation therapy, and/or biological therapy to: Shrink a tumor before surgery or radiation therapy. This is called neo-adjuvant therapy. Help destroy any cancer cells that may remain after surgery and/or radiation therapy. This is called adjuvant chemotherapy. Make radiation therapy and biological therapy work better. Help destroy cancer if it recurs or has spread to other parts of the body from the original tumor

Cancer Treatment Diagnosis of Cancer Chemotherapy Radiation The cancer treatment may include the following: Surgery Chemotherapy Radiation Hormone therapy Biological therapy Complementary and Alternative Therapies Clinical Trials “Watchful waiting” These slides will accompany diagnosis in a longer presentation which expands beyond screening and early detection. Surgery removes tumor, organ and surrounding cancerous tissues Radiation uses high power x-rays to kill cancer cells in the body Chemotherapy uses drugs to destroy cancer cells Hormone Therapy uses drugs to stop or change hormone production, preventing cancer cells from getting and using hormones Biological Therapy improves the body’s natural ability to protect itself, helping the immune system fight cancer more effectively. Complementary and Alternative Therapies includes traditional healing, acupuncture, meditation, bio-feedback, yoga, imagery, herbs, natural foods, massage, tai chi, naturopathic medicine, homeopathy etc. Clinical Trials are research studies to find better ways to treat cancer, comparing the standard treatment with a new treatment. Medicare covers many of the costs associated with clinical trials. Watchful Waiting is observation, closely monitoring a patient's condition but withholding treatment until symptoms appear or change.

Cancer Treatment Decisions Diagnosis of Cancer Cancer Treatment Decisions Treatment decisions take into consideration several factors: Type of cancer Size of tumor Location Stage of disease Elder’s health status Treatment side effects Prognosis Quality of Life

Coping With Side Effects Diagnosis of Cancer Coping With Side Effects Side effects and intensity vary, from person to person and even with each treatment. Eating well, continuing to be physically active, getting rest and support during treatment may ease side effects. Inform your health care team of side effects experienced and ask for assistance in treating pain, nausea, mouth sores, radiation burns and other treatment complications. This slide can be used to begin discussion from the survivors and family members, to share their stories and what helped to improve their treatment experience. Side effects Many cancer treatments may damage healthy cells and tissues in addition to cancer cells, resulting in side effects. Side effects and intensity vary, from person to person as well as with each treatment. Care During Cancer Treatment Eating well, continuing to be physically active, resting adequately and getting support during cancer treatment may lessen or ease side effects.

Becoming Well Again Diagnosis of Cancer Bringing a sense of balance back into life is important: Getting back into a routine, Resuming meaningful activities, Choosing activities that have a purpose, Spending time with friends and family, Sharing stories and laughter, Resting and taking care of themselves. Elders benefit when they receive support and care. The concept of becoming well again is important to all age audiences and is a wonderful discussion point for you to allow enough time for. Elders benefit when they receive support and care. Emotional, spiritual and practical support can be offered by family, friends, neighbors, health care providers, clergy and cancer survivors.

Cancer Survivorship

Cancer Survivorship Survivorship begins at the time of the cancer diagnosis and continues throughout the life of the elder. Cancer is emerging as a chronic disease, rather than a terminal disease, for an increasing number of survivors. In 1971, fewer than half of cancer survivors lived 5 years beyond diagnosis. Today the 5 year cancer survival rate is 65% for adults and 79% for children ages 14 or younger. Families are also survivors - 3 out of every 4 American families have been impacted by cancer. Source: NCI Office of Cancer Survivorship http://survivorship.cancer.gov The concept of Cancer Survivorship was included here for a caregiver audience, but many elders also are very responsive to it.

5 Year Cancer Survival Data, US Cancer Site 1995-2001 All Sites 65% Prostate 100% Melanoma 92% Urinary Bladder 82% Breast (female) 75% Rectum 65% Colon 64% Non-Hodgkin Lymphoma 60% Leukemia 48% Ovary 45% Lung and Bronchus 15% Pancreas 5% Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan Share the best news first. The leading cancers are highlighted.

Important Cancer Conversations To Have With An Elder You Care For Ways to lower your cancer risk Importance of screening and early detection Facing a cancer diagnosis Making informed treatment decisions Questions to ask your health care provider Finding the latest, most accurate cancer information Receiving support during cancer treatment Fears that cancer will come back Accessing palliative care and pain relief Advance directives and end of life planning This is in many ways, the point to turn the discussion over to the audience in small groups to share stories by offering them ways to engage and elder in conversation. It can be simplified to inviting those in the audience to share with each other for a few minutes 1 on 1 or in small groups, then invite a few to share topics discussed. Or it can be a “take home” assignment to reach out to their loved ones.

Resources for Cancer Information

Resources for Cancer Information National Cancer Institute Web site: http://www.cancer.gov/ Live help (email) Monday through Friday, 5 AM – 7 PM AST NCI’s Cancer Information Service: 1-800-4-CANCER (1-800-422-6237) TTY: 1-800-332-8615 Please Call Monday through Friday, 9 AM – 4:30 PM AST Offering the latest, most accurate cancer information

NCI has recently launched a new interactive website, designed to help you understand cancer risk– “Cancer Risk: Understanding the Puzzle” at http://understandingrisk.cancer.gov. It’s a great site with highly interactive pages to help you learn about cancer risk factors, assess your risk and identify resources for reducing your cancer risk.

Thank You!