Archive for the Cancer Treatment category.
Colorectal cancer. Screening for colorectal cancer is recommended for everyone over the age of 50. Fecal occult blood testing is the major test. It should be done on an annual basis. The best way to do this is not by doing a digital rectal examination and then smearing the stool on a card. It is best done by sending the patient home with three stool hem occult cards and having them mailed back to your office. That’s so there are three different specimens done where the patient is on a special diet prior to doing the test. This is one of the places where the American Cancer Society beat out the Preventative Health Services task force. The ACS has been saying for years and years and years, that all patients should have flexible sigmoidoscopies starting at the age of 50, every two to three years. U.S. Preventive Health Services task force said, no, there’s no data to support that, until their most recent edition where, based on a very good case controlled study which showed a decreased risk of dying from colorectal cancer if a patient had undergone flexible sigmoidoscopy. The recommendation is now to do so. It is unclear what the interval should be. There are some who say between every three to five years. Some, Preventative Health Services task force leaves this unclear, but says perhaps once every ten years would be useful. And, by the way, the different … I don’t do flexible sigmoidoscopy, so I refer to gastroenterologists to do it and each one gives me back a slightly different recommendation on a normal exam, about when the next one should be done. Canadian viagra at Canadian health care.
Of course, if a person has fecal occult blood positive stool, colonoscopy is, I think, considered the community standard for the best follow-up test. Most of us would consider barium enema evaluation or flexible sigmoidoscopy after a known positive occult blood test, to be inadequate. There are some high risk groups. A first degree relative with colorectal cancer; it is unclear, still, if the increased risk of having a first degree relative justifies the use of colonoscopy over other screening methods. That increased risk, though, may justify beginning screening before the age of 50; and many of the members of my group, without data to support this, actually start recommending screening colonoscopy to patients after the age of 40 if there is a first degree relative. There is no data to support that, but at the moment, that is where we are as a community standard. We also believe that you need increased surveillance for patients with familial polyposis, ulcerative colitis, a previous history of known adenomatous polyps, or previous history of colon cancer. If you are watching the literature, it’s also unclear that once you do a … if you do a screening colonoscopy, when should the next one occur. And that is changing from every three to every five, to perhaps every ten years.
Cervical cancer. Regular pap tests are recommended for all women who are sexually active. There is little evidence that annual screening is better than every three year testing. But this is assuming that you are sitting with a patient who is at standard risk, and these are risk factors that do not make you standard risk. So early onset of sexual intercourse, multiple sex partners. One question is to get an agreement as to what does multiple mean. Cialis professional - erectile dysfunction treatment. Is that two, is that three, is that four, is that five partners? Or is it more likely to be the case where you have one partner who has multiple partners, which might be a more significant risk problem. Low socioeconomic status. HIV infection; the recommendation is still every six month pap smears in patients with HIV disease. This is because it is known that human papilloma virus, which is the virus that is known to probably induce cervical cancer, seems to grow faster in patients who are HIV positive. Of course, if there is a previous history of abnormal pap smear, that patient should have ongoing annual exams. The thing we like to argue about is what about patients above the age of 65? Should they be undergoing pap smear screening and how often? By the way, the American College of Obstetrics and Gynecology says, “Yes they should be getting them on an annual basis.” There is no data to support that.
The other question is, what about the indication for pap testing in women who have undergone hysterectomy? There is a recent article in the Journal of American Medical Association looking at a large number of women who had undergone total hysterectomy, meaning that their cervix had been removed along with the uterus, which is the standard procedure now. And it’s been shown that basically if you are doing it, what you are really screening for is vaginal cancer. You are no longer screening for cervical cancer. Vaginal cancer is extraordinarily rare. Random pap smear scrapings of the vaginal mucosa are probably useless for making that diagnosis. So based on data, there’s no reason to do it. By the way, in my group, there’s no data but what we do is if a woman has had all normal pap smears consistently before the age of 65, we would sort of drop down to once every 3-5 years screening women past the age of 65. But if you happen to see, which I still do, every now and then you see a patient who is not … I see her at 67 for her hypertension and then find out that she hasn’t had a pap smear for about 20 years or since the birth of her last child, that patient, I believe in more intensive screening for a few years.
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What Is Complementary Medicine?
Complementary medicine is used to describe therapeutic techniques that are not part of conventional medicine (also called “regular,” “standard,” or “mainstream” medicine). Complementary therapies are used as a “complement” or addition to conventional medicine. Because complementary medicine can be combined or integrated with conventional medical treatment, it is also called “integrative medicine.”
Conventional medicine has been proven to be safe and effective by numerous scientific studies. While some studies show that people diagnosed with breast cancer can get benefits from complementary medicine, it’s important to know that complementary therapies usually don’t undergo the same kinds of rigorous testing as conventional medicine.
Complementary medicine includes techniques such as acupuncture, herbal medicine, massage, support groups, and yoga. Sometimes called holistic medicine, complementary medicine typically addresses how disease affects the whole person: physically, emotionally, spiritually, and socially.
Because their effect on the body is best described in nutritional terms, Breastcancer.org discusses supplements and herbs in our Nutrition section.
The difference between complementary medicine and alternative medicine
Alternative medicine is not the same as complementary medicine. Complementary medicine is USED WITH conventional medicine. Alternative medicine is USED INSTEAD OF conventional medicine. Breast cancer treatment.
It might help you to add yoga, tai chi, or massage to your regular treatment plan. But you should NEVER replace any part of your regular treatment (surgery, chemotherapy, radiation, hormonal treatment) with something else. Therefore, Breastcancer.org does not recommend alternative medicine.
A number of studies have found that more than 70% of breast cancer survivors have used at least one complementary technique.
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When we speak about radiation oncology, on the biological level. What we’re trying to do is kill a cancer cell. What one has to realize is radiation is effective only in microscopic disease for the most part, and it’s not effective during the entire time period that the radiation is being given. The reason is, if you look at the biology of cancer, and you think about the dividing cell, the majority of a cancer mass does not divide at any one time, only about 10% of the cancer is dividing, so if you look at the cell cycle, what you see is that the majority of cells are what we call the G0 phase in a tumor mass, 90% of the cells are actually resting. For radiation to be effective, these cells have to be recruited out of their resting phase and have to be actually dividing because radiation will kill a cell when it’s either in the mitotic phase or beginning from the resting phase or the G2 phase.
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The clinical implication of this is that one sees the maximum effect of radiation, not during the time of radiation but within three to four weeks after a patient completed radiation therapy. The reason we give a small dose initially of 180 to 200 rads is that lower doses, the cell has the ability to repair the damage of the radiation and that is called the sublethal effect. That is this little slope you see here. As you get over 200 centigrade, you begin to see the higher the dose, the more likely the cancer cell will be killed. Radiation therapy is based upon what we call the Compton effect, what the Compton effect is, is that when a photon or an x-ray hits a cell, it will go ahead and eject the nucleus from the outer shell of the cell of the atom producing what we call a scatter photon, and what you have to remember is x-rays are like energy or photons. This is the way radiation works. Radiation doesn’t work in large masses because the majority of cancers have a hypoxic out nucleus or have necrosis.
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When angiogenesis takes place, and there is a vascularity, what happens is the vasculature oxygenates the center of the tumor mass and what we have found over the years, is the more oxygenated the cancer mass is, the greater the likelihood the cancer will die and here you have a comparison of what happens when cell are in a toxic background or no oxygen and when there is oxygen present. As you can see, treating cells with radiation what you will see is that there is a greater ability to kill the cancer cell when oxygen is present. This is important clinically because when a patient goes for radiation therapy, we like the patient not to anemic and to be transfused with a hematocrit over 30. This is the basis for it. When you send a patient to radiation oncology, they always give you a dose, 10 years ago what we used to report is dose in rads, and what rads was radiation absorbed dose. A patient would get for example, 4 to 5 thousand rads of external beam radiation therapy. However, the terminology has changed and what we now talk about rather than rads is centigrade and centigrade is if you pick up an older chart, you convert rads to centigrade by remembering that one rad is equivalent to one centigrade, 100 centigrade is equivalent to one grade, so if a patient receives 40 grade, they have received 5,000 centigrade or 5000 rads, they are all equivalent. Herbal xanax.
Simple hysterectomy and bilateral salpingo-oophorectomy remain the hallmarks of therapy for corpus cancer. After complete surgical staging, if disease is limited to the uterus, most patients need no further therapy. The one exception is patients with a poorly differentiated, deeply invasive cancer. Nonrandomized studies controlled for prognostic factors suggest that pelvic radiation in this group may prevent both local and distant recurrence. In all other instances, radiation therapy did not appear to be of benefit. In the only prospective, randomized study comparing radiation with no radiation, it appeared that radiation decreased local recurrence but overall survival was the same.
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The role of brachytherapy postoperatively does not appear to be efficacious in most surgical stage I cancers because vaginal vault recurrence appears to be no more than 1-2%, irrespective of whether the patient receives radiation. Fortunately, most adenocarcinomas of the endometrium are surgical stage I, and most of those are adequately treated with surgery only.
When disease is present outside of the uterus, there is no general agreement as to optimal therapy. Unfortunately, prospective, randomized studies have not been done, and the clinician’s experience, both published and unpublished, affects the therapeutic recommendation. The question that has been raised is whether surgical staging is only diagnostic and therefore has no impact on survival. Data are now appearing in the literature suggesting that lymphadenectomy can be therapeutic to a greater degree than simple hysterectomy and bilateral salpingo-oophorectomy patients with true stage II disease has not been investigated in any depth. Again, most oncologists would probably treat these patients with postoperative radiation, although some have suggested that surgery may be definitive, particularly for those with stage IIA cancers. The role of radical hysterectomy in patients with clinical stage II disease has essentially been discarded from our armamentarium. In patients with surgical stage III and IV disease, treatment is usually individualized and combination therapy with surgery and radiation is common. The use of chemotherapy and hormones both in adjuvant and therapeutic modes in patients with advanced disease has not proved to be efficacious. Multiple regimens have been attempted, but response rates remain suboptimal.
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Recurrent disease historically has been treated in many different ways. If a local recurrence appears in the vaginal vault, surgery alone or in combination with radiation therapy has saved many of these patients. If recurrence is in the lower vagina, success has been limited. For metastatic disease, progestins have been primarily used; reports have noted an objective response in about one third of patients. More recent data suggest that the response rate is 15-20%. Original grade of tumor, length of time from primary treatment to recurrence, and hormone receptor status of the original tumor all appear to be indicative of the patient’s response to progestin. Several cytotoxic agents have been used with objective responses noted. The most experience has been with adriamycin and cyclophosphamide, cisplatin with or without adriamycin, and more recently paclitaxel. Unfortunately, when there is a response, it is relatively short lived. The ideal single or combination regimen for recurrent endometrial cancer has not yet been identified.
Just some real quick characteristics about the drugs that I think will help your patients. First of all, I know - remember what I showed you on that chart - that Tylenol is better than codeine. I know your most common prescription is Tylenol number 3, one or two every four to six hours p.r.n. pain. Now the fact is, the drug only works for four hours but when you have pain and you take Tylenol, do you ever take one? Doesn’t work does it. You have under-dosed the best drug in the combination when you tell a patient to take one T3. Now I don’t want to suggest that you change your prescribing practices, because I know you can’t - I’ve been around awhile - but what I suggest is that next time you write that order you tell the patient, “When you decide just to take one, take a plain Tylenol with it.” It will work much better, it really does.
Hydrocodone: you’ve heard me take a couple of shots at Vicodin. Now Vicodin is an excellent drug, it really is. Vicodin now is combined with ibuprofen and Vicoprofen. These are real good analgesics. If was going to take something like that I would much prefer to take Vicodin than Tylenol with codeine because I think it’s a much better analgesic. The problem is that physicians as a group - I’m not talking about you individually - are afraid to write schedule II prescriptions. You are. You will go through all kinds of mental gymnastics to convince yourself that you can write a schedule III or that the patient doesn’t need a schedule II. With severe herpes pain, you can’t treat it with a moderate analgesic. So what happens is you write Vicodin when the patient needed morphine or oxycodone. The patient takes the Vicodin, it takes the edge off but they still hurt a lot. They now have two choices: follow your directions or double the dose. You want to guess what they are going to do? They are going to do what you would do if it was your pain. So now you’ve got a patient taking two Vicodin ES every four hours - there’s 750 mg of Tylenol in a Vicodin ES - so two times six, times 750 is 9 grams of Tylenol a day. That’s the problem with these hydrocodone products. They are a wonderful drug but only for moderate pain. For severe pain you’ve got to use strong opiates.
Methadone is a great analgesic. Tricky to use. We used to use it a lot for cancer pain before we had the controlled release forms of morphine available. We seldom use it now, in fact, most teaching hospitals avoid it like the plague because it’s so tricky to use and the residents can’t figure out the complex dosage reductions that have to be done to keep patients out of trouble. So we just don’t use it very much. If you use it in your practice then you understand how to use it. It’s advantage is it’s cheap. But understand that if you are using it, that the patient’s methadone half life is roughly equal to their age in years. And that’s a pretty accurate statement about methadone. The patient’s methadone half life is roughly equal to their age in years. So if you are giving it to me and we start out today, I’ll reach steady state in about 300 hours. Which is May something. Really.
This is the problem with meperidine. At therapeutic doses it’s toxic. The therapeutic dose of meperidine, the amount designed to relive severe acute pain, in 2/3 of the instances is 100 mg every three hours. The drug only works for three hours. I know - unless you are really unusual - if you write meperidine you write 50 to 75 mg every four to six hours p.r.n. pain. If the patient starts asking for it every three hours, the nurse comes to you and says, “He really likes this stuff” and so you cut the size of the order. But the therapeutic dose is 100 mg and it only works for three hours. So the problem is that that dose is toxic. At safe doses it’s relatively ineffective. It’s not what you want to have to treat your pain. Now I will make a confession. My chart says, “Allergic to Demerol.” I’m not. Now that’s not a problem here because the people who provide care here - if we are going to prescribe severe stuff for severe pain - they let me do it my way.
Levo-Dromoran is a good drug. We don’t use it that much anymore because we have sustained release products. Oxycodone, the opiate in Tylox and Percocet, Percodan, is really good. Again, if you are using those products use enough peripheral analgesic. There’s only 300 mg acetaminophen in a Percocet. There’s only 225 aspirin in a Percodan. We have a controlled release product available now, OxyContin, which is really good for chronic non-malignant pain because it doesn’t have a distribution phase. The drug has two release characteristics and its level looks like this, so it’s not a lot of fun to take.
Morphine is the gold standard. This is what we measure everything else against. The sustained release products are called the most effective and cost effective therapy.
New Treatments for Cancer Pain
And we are really afraid of opiates. Your neighbors are afraid of opiates. The people you go to church with are afraid of opiates. We can’t change their irrational fears but there is something that I want to suggest to you that will really increase the compliance of your patients in taking the medications you prescribe. Patients are afraid of narcotics. Cocaine - I’d like you think of it this way - from this day forward, marijuana is a narcotic, heroine is a narcotic, cocaine is a narcotic. All the things you prescribe for severe pain are opiates. Opiates are medicine. It works. I know it sounds hokey, but it really does work. Refer to them as opiates. Opiates are medicine. Taking medicine the way your physician prescribes it is called compliance, not drug abuse. And you need to tell them that too. “It’s really important that you follow my advice.”
We have other strong opiates. We have short-acting strong opiates, Dilaudid, Demerol, morphine and OxyContin we have long-acting strong opiates, topical Fentanyl, Levo-Dromoran, methadone, sustained release morphine and sustained release OxyContin.
This is the hierarchy of effect when you give a patient a strong opiate. The only guarantee is constipation. You must have a reflex. You must never write for a strong opiate without writing for a stimulant laxative and a stool softener. Opiates cause constipation by three mechanisms, two of which we can affect with drug therapy. One of the mechanisms that we cannot effect is that it alters enzymatic action in the bowel. I increases the resorption of water from the bowel and it slows motility. So we have to give them a drug that increases water retention in the bowel and a drug that stimulates activity. Analgesia is the second most common event. If I, right this minute, gave each of you a 10 mg dose of opiate, a 10 mg dose of morphine, the most predictable outcome would probably be vomiting, but the most common event would be dysphoria. For patients without pain almost all of them find opiates unpleasant. They don’t make you feel good.
I need to explain to you about opiate potencies because I know, if you have been paying attention at all to what the drug company salesman has been saying, it’s confusing. Because they all have a different story. The FDA, when they assess opiate potencies, they do it very differently than any other drug. They take the super, the little 5% sample. That says the drug is super-potent and they use it. First of all, they don’t want to get screamed at by some senator running for election next year, they want to do no harm and they are absolutely convinced that if it’s not enough you are going to change the dose tomorrow anyway. They don’t know that the patients don’t tell you it’s not working, they increase it on their own or whatever. And the drug companies love this because they do their pricing based upon the cost of the other guys therapy. My proof? When Nalbuphine was introduced, it says Nalbuphine is milligram for milligram as potent as morphine. Well, it is as a sedative, but as an analgesic it takes 1 ½ to 2 times as much. Same thing with Butorphanol. They said 2 mg equals 10. Doesn’t. Takes 3 to 4. When meperidine was introduced it says 50 mg of Demerol equals the analgesic potency of 10 mg of morphine. Wrong. Takes 100. Fentanyl patches are twice as good as Jansen says they are. And Purdue-Frederick is now saying that OxyContin is twice as good as morphine. I don’t think so. I think it’s 1 ½ times.
What I suggest however, is that you use those conservative potencies but understand that on day two you need to get a report back from the patient on how they are doing and adjust the dose based upon t he patient response. Because about 10% or so will respond to those lower doses. About 80% will respond to a higher dose and 10% will need a much higher dose. Remember there’s a 10% over here that needs lower doses, there are people who are going to need higher just because it balances out the human response curve.