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Dr West

FAQ: How Much Does Attitude Matter When Fighting Cancer?

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Most people feel a loss of control when faced with a new diagnosis of cancer. You can meet with doctors, develop a plan, perhaps do surgery, radiation, chemotherapy, targeted molecular therapy,  immunotherapy, or some combination of these.  But beyond showing up and taking recommended interventions, how much does a positive attitude help?

While it’s comforting to think that you can control much of your outcome and some argue that a positive attitude makes all of the difference, cancer experts are largely humbled by how little control we have over the outcome, even with the many potentially effective tools we have at our disposal. Patients need a positive attitude in order to pursue the treatments that can be very effective rather than just giving up, but the truth is that a positive attitude can’t overcome a very aggressive cancer biology.

It would be nice to live in a world where a positive attitude makes all of the difference in overcoming a nasty cancer, but to be honest, that’s a make-believe world of rainbows and unicorns. 

 Rainbows and unicorns

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Dr West

FAQ: What is “Performance Status” and Why Does it Matter so Much?

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Along with a patient’s age, sex, and past and current medical issues, performance status (PS) is one of the most important factors that is categorized for patients. It essentially refers to a patient’s ability to manage his or her activities of daily living — things like bathing, dressing, feeding yourself, etc., as well as general activity level and ability to do whatever work they need to do. 

There are two leading scales for measuring PS. The most frequently used one, known as the Zubrod or ECOG scale,  simply goes from 0 to 4, with 0 representing no symptoms or limitations, and 4 representing being bedridden and completely unable to care for yourself.  

Zubrod PS

 

The alternative is called the Karnofsky PS scale, describing the range of activity from fully functional (100%) down to 10%, bedridden; obviously, this is essentially the same range, but with finer grading, as if you could assign half points on the Zubrod scale. Here’s the description of the levels on the Karnofky scale:

Karnofsky Performance Status PS Scale

Though this scale suggests that there is a clear number for everyone, it is more fair to acknowledge that PS is somewhat in the eye of the beholder.  Certainly, one person’s 70% Karnofsky PS may be 60% to someone else, and this may depend on how well a person happens to be doing on a given day at a given hour.  This may be part of why the Zubrod PS scale is more widely used: it doesn’t put too fine a point on a subjective measure.

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Dr West

FAQ: What is Neoadjuvant Therapy and Why Would We Want to Give it?

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The cornerstone of treatment of an earlier stage cancer is a local therapy such as surgery or radiation, which is meant to remove or destroy the cancer that is limited to a specific area. We know, however, that people who have undergone complete resection or what should be complete destruction of a tumor by radiation will too often have their cancer return, sometimes near the area where it first appeared, but often in a distant location.  When we see the cancer recur in a distant site, we can presume that this was mediated by “micrometastatic” disease, circulating tumor cells that were too small to be seen on any scans or by a surgeon directly at the time of surgery, but which must have remained in the body after a good local treatment removed or destroyed all evidence of visible disease. In order to combat this risk and try to treat potential micrometastatic disease, we often give systemic therapy before and/or after the local therapy.  A particularly common approach is to follow surgery with chemotherapy, which is called adjuvant therapy, with adjuvant meaning “helper”.  Systemic therapy before surgery or possibly before radiation is typically termed neoadjuvant therapy, and there are a few reasons why we might prefer to give systemic therapy at the earliest opportunity, rather than having it follow the potentially curative local therapy.

 

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Dr West

Imaging FAQ: My scan report describes changes in the bones. What do they mean? Is my cancer progressing or responding to treatment?

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A common question that arises around imaging is the significance of changes in bone lesions over time and treatment.  Unfortunately, these lesions are notoriously difficult to interpret, with responses to treatment often looking so much like progression of existing lesions that we can’t tell the difference reliably.  So what can we do?

Essentially, we ignore them, subtracting them from our interpretation of a repeat scan.  We don’t consider bone lesions to be “measurable disease” by the formal criteria used to assess response to treatment in our clinical trials.  Instead, the only way that bone lesions are incorporated into assessing response to treatment is when a new lesion appears. That can be interpreted as progression. But otherwise, our interpretations of existing bone lesions just can’t be interpreted with enough confidence to infer whether they support a response or progression. 

 


Cancer 101 FAQ: My oncologist told me my counts are low, so I need to delay my next chemo treatment? Is this going to be harmful?

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It’s not unusual to need to delay treatment and adjust the chemotherapy dosing based on low blood counts or other side effects. That approach is built into our standard treatment algorithms to account for the variability in individual people and a need to keep people as safe as possible during aggressive treatment. Standard dosing is conventionally based on a typical maximal tolerated dose for a given drug or regimen, meaning that you often run on the high side and therefore may well need to gradually adjust the treatment dose based on real-time feedback of a person’s low blood counts or other treatment-related prohibitive side effects. It’s therefore a common occurrence and not a terrible complication to need to delay the next treatment and/or lower the treatment dose over the course of therapy.

In terms of the interval of treatment delays, there’s no clear best answer, but delays are often arbitrarily given in week intervals. This is often in the ballpark of the amount of time it takes for blood counts to recover from prohibitively low levels to a threshold for safe administration of further chemotherapy. If we assume that three weeks between treatments is the standard for a particular regimen (such as a single day every three weeks or days 1 and 8 of a 21 day schedule), and some people need an extra week or two for their blood counts to recover to a safe level, that’s delay isn’t a meaningful break in terms of a gap in treatment (for better or for worse — it isn’t much “time off” to either feel better or not be actively treating the cancer, depending on your greater concern), but instead is just the required time to recover from the ongoing effects of the most recently administered treatment. We consider the chemo to be working during that time. It’s also important to know that if counts are low, the risks of delaying a week or two for counts to recover to a safer level, and/or the risks of lowering the dose of treatment, are very likely less than than the risks of infection, bleeding, etc. that may occur from treating too early.

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