About Cancer

Studies have suggested that there is a link between smoking and bowel cancer. The evidence suggests that people who smoke for many years have are between one and a half and three times more likely to get a bowel cancer than non-smokers.

The increased chance of getting a bowel cancer does seem to be associated with long-term smoking, with people who have smoked for more than 35 to 40 years being at risk.

Radiotherapy uses a type of radiation, called ionising radiation, to destroy cancer cells. There are several types of ionising radiation including x-rays, gamma rays and beta rays.  Most radiotherapy treatment for cancer use x-rays.

Ionising radiation works by releasing chemicals in the nucleus of cells. These chemicals, called free radicals,  damage the DNA, the genetic material that is vital for the cell to multiply.  If the DNA is sufficiently damaged by the radiation then it will not be able to divide and will die off.

In order for the radiotherapy to release the free radicals that damage the DNA there needs to be a good supply of oxygen in the cells.   If the cells are starved of oxygen then this actually protects them against the effects of the x-rays and makes treatment less effective.

Oxygen is carried to the tissues and cells in our bodies by the haemoglobin in the red blood cells. If we are anaemic then the haemoglobin level in the blood is low, and so the amount of oxygen carried by the blood to our cells is reduced.

So in order to get the best results from a course of radiotherapy it is important to be sure that you are not very anaemic before you start treatment. 

If you are anaemic then your doctors may well suggest a blood transfusion before you start your treatment.  This will boost your haemoglobin level and will increase the oxygen in your blood, which will increase the chances of success from your radiotherapy treatment.

Many people are frightened about the prospect of chemotherapy, particularly because of all the publicity that has been given to possible side effects. However, modern chemotherapy and medications to avoid or reduce side effects have made chemotherapy better tolerated for most people.When a bladder cancer has spread to other organs in the body then treatment with chemotherapy,  is designed to try and shrink the growth, improve symptoms,  maintain a good quality of life and to prolong life, if possible. Unfortunately at this advanced stage of the cancer a cure isn’t possible, and making decisions about treatment in these circumstances is always difficult.

If you do have the chemotherapy it is possible that this will lead to control, and possibly shrinkage, of the cancer with relief of any symptoms, improvement in quality of life, and maybe even some prolongation of life. These benefits still cannot be guaranteed. Some people will have significant benefit while others will have no improvement at all and will therefore have the side-effects of the treatment without any benefit. The fitter a person is  generally the more likely they are to have benefit and less likely to have side-effects.

The alternative to having chemotherapy would be to have ‘supportive treatment’ which is aimed not at controlling the cancer itself but at easing any troublesome symptoms and maintaining quality of life. This would usually  mean ‘non-chemotherapy’ medication like steroids and pain killers, and occasionally a short course of radiotherapy. There would still be contact with a medical and nursing team to oversee your care during this time. So not having chemotherapy does not mean that you would be left to cope on your own.

The choice of treatment is a difficult one and will depend on your own feelings at this time, so  it is important to talk this through with your specialist, about the potential benefits of chemotherapy in your own situation.

Category: BLADDER CANCER

When a good friend or a relative gets cancer it is often a very difficult time and people often handle the situation by cutting down the number of visits and meetings because they might be difficult or distressing. Although this is understandable it is often very upsetting for the person who has the cancer who can find themselves apparently deserted by long-time friends and members of the family at a time when they really need them. So the first way in which you can help is simply by keeping in touch and keeping up with your regular contacts just as you did before the cancer was discovered.

There are then two main ways in which you can make a difference: by giving emotional support and offering practical help. The best way to make a start with these is by talking, or perhaps even more importantly, by listening.

Everyone is different and some people with cancer will find it very helpful to talk about their illness and its treatment whilst others cope by acting as though everything was normal and life was going on as usual, so knowing just the right thing to say is difficult. If someone is happy to talk about how they feel and how they are coping then listening sympathetically can be very useful indeed and make a real difference. If they are less forthcoming and keeping things more to themselves then direct questions like ‘how are you feeling?’ or ‘how are you managing?’ will probably get short answers like ‘fine’ or ‘OK’ and lead nowhere. On the other hand using questions asking about specific aspects of well being, like ‘how are you sleeping?’, ‘do you get very tired?’, ‘what sort of things do you enjoy eating?’, can be easier to answer and can often get people talking more about how they are and what problems there might be.

This can also open opportunities for practical help, things like doing a bit of shopping, walking the dog, taking your friend to the hospital for their next appointment, taking the children to school one morning a week and a hundred and one other possible ways in which quite small things you could do would not only make the day to day chores of life a bit easier for your friend but also show her that you do care and are there to help her.

For a while at least your friendship may be under strain, especially if your friend is having great difficulty in coping and coming to terms with the diagnosis and its treatment but by keeping in touch, by ‘being there’ and letting them know they can rely on you then you will be making a real contribution to their quality of life at a time when it really matters. .

Category: BLADDER CANCER

It is very common for people with cancer to have problems with sleeping at night. This may be because of general anxiety, fears about treatment or worries about the future. All of these reasons are very understandable but they can lead to insomnia with either difficulty in getting off to sleep or waking up during the night and having trouble dropping off again.

If this continues and starts to affect your quality of life then you could chat to your General Practitioner about the possibility of tablets to help you sleep. Many people, however, prefer to avoid sleeping pills and there are a number of tips to offer about ways of helping to get a good night’s rest which you might like to try as an alternative. These include:

  • establish a regular routine of going to bed at about the same time each night and waking up about the same time each morning
  • if you are able to manage some regular, gentle, exercise during the day (such as having a walk for half an hour) then this can help deepen sleep
  • a warm bath just before bedtime, with the addition of soothing oils or essences (such as lavender oil or geranium oil) is very relaxing
  • a warm, milky, drink just before bedtime will avoid hunger during the night, which can disturb sleep
  • alcohol can make you feel sleepy but it often disrupts the sleeping pattern during the night so avoid large amounts of wine or spirits just before bedtime
  • tea, coffee and cola drinks all act as stimulants and are best avoided for a few hours before going to bed as they tend to keep you awake
  • some people find that a few drops of lavender oil sprinkled on their pillow helps them relax and sleep better
  • if you sleep a lot during the day try seeing if you can cut back a bit on daytime naps
  • work out just how much sleep you need in order to feel refreshed the next day and avoid spending too long in bed as trying to sleep too much can actually lead to disturbed and shallow sleep
  • if you wake up during the night and can’t get back to sleep after a few minutes and are unable to relax (just lying quietly can still be very restful if you are relaxed but not if you are tense and worrying) then try reading a book or watching television for a while or listening to tapes, like talking books, on a personal stereo or make a hot drink

Although sleep disturbance is quite normal and understandable for people who are worried about their cancer occasionally insomnia can be a sign of underlying ‘clinical’ depression which does need medical treatment and can be very much helped by simple medication. Key symptoms of depression include:

  • a low mood for most of the time
  • not feeling your usual self
  • not being able to be taken out of your low mood by yourself or your friends
  • loss of interest or enjoyment in your favourite activities as pastimes

If you are experiencing these problems as well as your sleeping difficulty then it would definitely be worth having a word with your doctor to check on whether or not you are developing depression. .

Category: BLADDER CANCER

Unless it is treated a cancer will usually continue to grow, sometimes slowly, sometimes more quickly. At some point during its growth it will often send of seedlings of tumour to other parts of the body. The lymph nodes (lymph glands) nearest to the growth are frequently the first place these seedlings spread to and then they travel more widely to other organs in the body. This process of development is often called the ‘natural history’ of the cancer.

When a cancer is first diagnosed it is important for doctors to be able to tell how far it has progressed, whether it is still in one site (the primary tumour) or whether it has spread to other places (forming secondary cancers or metastases). This will let the medical team know what stage the cancer is at in the journey through its natural history. The information on the ‘stage’ of the cancer is then very valuable in deciding what is the best treatment and what the outcome of that treatment is likely to be. There are hundreds of different types of cancer that can affect the human body and different cancers can behave very differently.

Over the years specialists have worked out ‘staging schemes’ for all the main types of cancer. These staging schemes lay down a set of rules which allow doctors to work out how far the cancer has progressed, what ‘stage’ it has reached. The TNM system is one of these staging schemes.

The initials T, N and M stand for ‘tumour’, ‘nodes’ and ‘metastases’. T describes the size and extent of the ‘primary’ tumour, the starting point of the cancer. N says whether or not the lymph nodes are affected by the cancer , and how extensive that involvement is. M says whether or not there is spread to other organs elsewhere in the body. Depending on how big the growth is and how widely it has spread different numbers and letters are added after the initials T, N and M to exactly identify the ‘stage’. So, for example, a small breast cancer which had not spread to the lymph glands or other parts of the body would be a T1, N0, M0 cancer, whereas a bigger breast cancer that had spread to the skin over the breast, the lymph nodes and the bones would be a T4b, N1, M1 tumour.

Because different sorts of cancer behave differently the TNM staging system varies slightly from one type of cancer to another, so the TNM staging of a bladder cancer will be slightly different from that of a breast cancer.

The system is complicated and what makes it even more confusing is that the TNM staging system is only one of a number of different staging systems used by cancer specialists (although the TNM system is standardised world wide and so means the same in different countries).

But although it is difficult the TNM scheme does give invaluable information which can be used to guide the choice of treatment and predict what might happen afterwards, as well as allowing doctors to compare the results of treatment for cancers of a similar ‘stage’.

Category: BLADDER CANCER

With modern day treatments many cancers are completely cured but unfortunately there are still many others which are not.
 
Although it is not always possible to be certain, doctors are often able to tell whether or not a particular cancer might be cured. Even if cancer is incurable they will usually still offer treatment in the hope of prolonging life and, controlling, symptoms.

For many cancers these treatments can be very successful and they can keep the tumour under control for many months and sometimes for years.
So lots of people with incurable cancer are still able to lead normal lives for long periods of time.

Only when the cancer finally fails to respond to all treatments does someone enter the ‘terminal’ stage of their illness.
Although there are no precise definitions for when a person becomes ‘terminal’ the word is usually used to describe the last few weeks, or months, of life.

A lot of men and women who have incurable cancers will live for a long time before their cancer becomes terminal.  With some slow growing cancers, especially in older people, it may be possible to have a normal life expectancy and die of another illness rather than of cancer.

Category: BLADDER CANCER

Cancer isn’t a single disease but is a description of a whole range of illnesses. In all there are several hundred types of cancer, each behaving in a different way, causing different symptoms and needing different treatment.

To make sense of this huge number of conditions doctors have devised ways of classifying cancers into groups which have some features in common.

The simplest, and most widely used, of these classification schemes is based on the type of cell which has produced the cancer. This gives four main headings which include the great majority of all cancers: carcinomas, sarcomas, lymphomas and leukaemias.

Carcinomas arise from the lining cells of the body (which are also called the epithelial cells). These cells from the outer layers of the skin and the membranes lining the digestive tract, the bladder, the womb and all the tubes and ducts which run through every organ of the body.

Sarcomas arise from cells which form the supporting tissues in the body (which is also called connective tissue). These cells are the ones that make up the bone, muscle and cartilage and also form the fatty and fibrous tissues in the body.

Lymphomas are cancers of the lymphoid tissue, which is part of our immune system. This tissue is found in the lymph nodes, the spleen, the bone marrow and the thymus gland (which lies behind the breast bone).

Leukaemias develop from the white blood cells which are circulating in our blood and also affect the bone marrow and spleen.

Carcinomas are by far the commonest of these four types of cancer, making up about 80%, four out of five, of all cases.

Carcinomas are themselves divided into subgroups depending on which type of epithelial cell produced the cancer and which part of the body it started in.

The four main types of epithelial cell are squamous, adeno cells, transitional and basal. Squamous cells are found in the skin, the lining of the mouth, the gullet, the airways and fine tubes in the lungs and some other parts of the body. Adeno cells form the lining of all the glands in the body, so any organ that contains glandular tissue contain them, these include the digestive organs (such as the stomach, bowel and pancreas), the breasts, the kidneys and many other sites. Transitional cells are only found in the lining of the bladder and parts of the urinary tract. Basal cells form one of the layers of the skin.

So, a cancer that starts in squamous cells, is called a squamous carcinoma. A cancer that starts in glandular epithelial cells, is called an adenocarcinoma, A cancer that starts in transitional cells is a transitional cell carcinoma and a cancer that starts in basal cells is a basal cell carcinom

These are then further described by giving the name of the organ or tissue where the cancer first began. So a cancer arising from the lining of the bladder would be a transitional cell carcinoma of the bladder, whereas a cancer arising from the glands in the breast would be an adenocarcinoma of the breast.

Some organs contain more than one type of epithelial cell and so can produce different types of cancer at the same site. For example, although the great majority of bladder cancers are transitional cell carcinomas the bladder does contain some glandular tissue so occasionally adenocarcinomas may develop instead.

The commonest site in the body for transitional cell carcinomas is wall of the bladder. Occasionally they may occur in the ureter, the tube joining the kidney to the bladder, or the part of the kidney that is closest to the ureter.

When a cancer forms in one of these organs it is called a primary cancer – so a cancer which first starts in the bladder would be a primary transitional cell carcinoma of the bladder.

All transitional cell carcinomas have the ability to spread to other organs and form secondary cancers there. When these secondary cancers form they are made up of cells which closely resemble and behave like, the cells of the original, primary cancer. So if cells from an transitional cell carcinoma of the bladder spread to the lungs they look and behave like bladder cancer cells, not lung cancer cells, and are called secondary bladder cancers. (Secondary cancers are also called metastases and so these tumours could also be called metastases from a bladder cancer or metastatic bladder cancer).

The type of treatment that might be needed and the success of treatment varies with every individual cancer. So to know more about your own condition you will need to discuss this with your medical team who will be able to put you in the picture.

Category: BLADDER CANCER

BCG is used in the treatment of the two main types of early, superficial bladder tumours, which are papillomas of the bladder and carcinoma in situ of the bladder. The first line of treatment for these tumours is to have them removed surgically but if they keep coming back, or if there are several growths present at the same time (as is often the case) then putting either chemotherapy drugs or a solution of BCG into the bladder may be recommended.

BCG is the vaccine which is used to protect against tuberculosis, TB. The use of BCG in bladder cancer is often called ‘immunotherapy’ as it is thought that it may stimulate the body’s own immune system to attack the tumour cells. But, in truth, no one is absolutely sure how it works. Nonetheless BCG is helpful for many people with either papillomas or carcinoma in situ and can prevent or delay tumours reappearing after surgery and also greatly reduces the risk of a more serious invasive bladder cancer developing.

The BCG solution is given directly to the lining of the bladder. A catheter is inserted through the urethra (the tube carrying urine from the bladder to the outside). The BCG solution is then instilled through the catheter into the bladder and remains there for about two hours. During that time you are asked to change position at regular intervals to circulate the BCG around the bladder.

The procedure can usually be done as an out-patient or a day-patient at hospital. BCG treatments are usually given once a week for 5 to 12 weeks.

Some doctors have given injections of BCG under the skin or suggested taking BCG solution by mouth, as well as the bladder treatment, but there is no evidence that doing this improves the results of treatment.

Common side effects include some discomfort in the bladder and when passing urine (often a stinging or burning sensation, which is called dysuria). Passing water more often for a day or two after the treatment is also common. About half the time there will be a little blood in the urine as well. 1 in every 4 people will notice a temporary fever for a day or so. Very very occasionally this fever does not settle after the first few days. If fever does continue it is important to have this checked by your medical team because BCG is a ‘live’ vaccine, this means that, rarely, it can actually cause the onset of tuberculosis. In the very unlikely event that this happens it is easily treated with appropriate anti-TB tablets.

Category: BLADDER CANCER

Although there are some cancers which may run in families , such as breast, ovarian or bowel cancer (even then most of these  do not develop from a genetic cause) most bladder cancers seem to happen for reasons that we do not understand and  but are not thought to be related to a genetic cause (an inherited gene from a parent which may increase the chance of a cancer).

There are risk factors which are known to increase the chance of developing bladder cancer. These include smoking, chronic bladder infections and exposure to chemicals from working in dye factories or the chemicals industry. However, even for people working in these industries it would take many years of exposure to these chemicals to cause a bladder cancer. If you do not have any of these risk factors, then you are no more likely to develop a bladder cancer than the rest of the population.

It can be natural to wonder what may have caused a cancer, particularly when a close family member has been diagnosed. Some families may have similar cancers in a number of family members but this can be due to them sharing lifestyle factors, such as smoking, rather than a genetic cause..

Category: BLADDER CANCER

Screening for cancer means testing people who appear to be well, and have no symptoms, in order to find tumours at an  earlierstage. If a cancer is detected early it is usually (but not always) more treatable, and more likely to be cured, than if it is found at a later stage. So a successful screening programme should improve the life expectancy of people with that particular cancer.

There are hundreds of different types of cancer – some are common, while others are rare. At the moment there is no way of screening to see if someone simply ‘has a cancer’ but there are screening tests for certain types of cancer such as breast and cervical cancer.

For screening to be useful for a particular type of cancer two conditions must be met:

  1. There must be tests that can be relied upon to find that cancer before it produces symptoms.
  2. There must be evidence that finding and treating that type of cancer at an early stage will improve the chances of a cure.

Although there are screening tests that are currently being tested in trials for bladder cancer, it will be a number of years before we know if they are effective in detecting cancer at an earlier stage, before symptoms occur.A problem in the past has been that too many people have test positive for bladder cancer when it is not present.

At the moment the only test that can reliably detect early cancers of the bladder is a cystoscopy and biopsy. This involves passing a cystoscope, (a thin flexible telescope), through the urethra (the tube that joins the bladder to the outside) into the bladder. Photographs of the bladder can then be taken and samples of tissue (biopsies) taken from any abnormal looking areas, for examination under the microscope. This test involves either a stay of several hours in hospital . It may be done with sedation or  under a general anaesthetic. Unfortunately it is not practical to do this examination on a regular basis on the whole population as a screening test forbladder cancer.

Cystoscopies are  used to monitor  people who have benign (non-cancerous) conditions which may turn into cancers. The commonest of these are called papillomas. Papillomas are non-cancerous (benign) tumours which grow out from the lining of the bladder into the urine-containing inner cavity of the bladder. They look like small mushrooms or warts. About 1 in 20 people who have bladder papillomas will eventually, often after many years, develop a bladder cancer. So if papillomas are discovered then people will be offered regular cystoscopies, at intervals of six to twelve months, to check that there are no signs of cancer developing.

Category: BLADDER CANCER

The bladder is a balloon-like organ, with an outer layer of muscle lined with an inner layer of cells called the urothelium.

Most bladder tumours develop in the cells of the urothelium. If the tumour only involves the inner, lining of the bladder it is called a superficial bladder tumour. If the tumour has spread from the inner lining into the muscle wall of the bladder then it is called an invasive, or infiltrating, bladder cancer. Superficial bladder tumours are about four times more common than invasive bladder cancers.

About 15-20% of people who have superficial tumours will eventually, often after many years, develop an invasive bladder cancer.

There are several treatments for superficial bladder tumours, and which treatment you have will depend on a number of factors including the type of tumour and its grade (how quickly growing the cancer cells are).

The usual treatment is to have a cystoscopy. This is when a small telescope, called a cystoscope, is passed into the bladder through the urethra, ( the  tube that joins the bladder to the outside). Superficial bladder tumours can be removed during this procedure which is carried out under anaesthetic. This is called a transurethral resection of a bladder tumour.

They can reappear after the initial treatment, sometimes in other parts of the bladder lining. So regular cystoscopies will need to be done to check for this.

If there are a large number of superficial tumours in the bladder, or if they keep coming back after surgery, then other effective treatments may be given. These can involve putting chemotherapy drugs into the bladder or ‘immunotherapy’, (using a vaccine called BCG, which once again is put into the bladder).

Category: BLADDER CANCER

The urachus is a tube, or canal, present during our embryonic development. It runs from the top of the bladder towards the umbilicus (the belly button). In the months before birth it gradually closes off and remains as a fibrous cord or ligament. How much of the urachus is still present in adults varies from person to person, sometimes there are traces of it all the way from the bladder to the umbilicus, but often there is just a remnant at the bladder end.

Cancers of the urachus in adults can occur but they are very rare.

They usually develop close to the bladder and are often mistaken for bladder tumours at first. But bladder cancers usually arise from the cells which line the inside of the bladder whereas urachal cancers, although they usually occur in the wall of the bladder, lie more deeply and are below the lining layer of cells. The cells look different under the microscope to those of bladder cancers.

Symptoms of urachal cancers include blood in the urine, abdominal discomfort and mucus in the urine. Because of the embryological remnants there may occasionally be bleeding or discharge from the belly button.
The main treatment for these tumours is surgery. Sometimes if the growth is very small this can be done with a partial removal of the area of the bladder where that cancer has appeared but as these tumours have a tendency to spread along the wall of the bladder a complete removal of the bladder is usually required. This operation is called a radical cystectomy and usually involves removal of some of the nearby lymph nodes as well.

Surgery is the most effective treatment for urachal cancers. Radiotherapy and chemotherapy may be used but do not do not appear to be very effective.  in treating urachal cancers.

Category: BLADDER CANCER

If a bladder cancer is present it will often causesome bleeding, although this may only  be  visible under a microscope (microscopic).). The presence of blood in the urine (haematuria) can be detected by simple urine tests, which can pick up even smalltraces of blood.

Unfortunately there are many different conditions which can cause haematuria. For example, a urinary tract infection will often lead to some blood in the urine. So detecting blood in the urineis not specific enough to help diagnose a bladder cancer.

Despite this, clinical trials have been done both in the UK and USA to see if looking for haematuria in apparently healthy adults might lead to greater detection of bladder cancer. But these studies have shown that even when haematuria is discovered, less than 1 in 10 people actually had a bladder cancer, and the conclusion was that routine urine testing simply isn’t an effective way of screening the healthy population for bladder cancer.

There are currently trials looking at other types of urine tests which may be more sensitive and accurate in helping to detect bladder cancer. However, it will be a number of years before the results of these trials are known. At this time there is no reliable method of screening the general population for bladder cancer.

Category: BLADDER CANCER

Major surgery for a bladder cancer usually means complete removal of the bladder (a total cystectomy). Urine produced in the kidneys drains into the bladder through two tubes called the ureters. The bladder then stores the urine until it is passed out through another tube, the urethra, which runs along the vagina or penis. If the bladder is removed then a new storage space for the urine will need to be created.

The most common way of doing this is to form a urostomy. This is done at the same time as the removal of the bladder.

Whilst you are under the anaesthetic your surgeon will remove a piece of your small bowel (ileum) and join the two ureters to one end of it. The other, open end will be brought out through the skin of your abdomen. The tube of bowel then forms what is called an ileal conduit, which acts as a channel to take the urine from the ureters to the surface of the abdomen. The small hole in the skin through which the urine now passes out of the body is called a stoma (the ileal conduit and stoma together are called a urostomy.)

The small bowel is rejoined after the section to be used for the urostomy has been removed. The removal of the short section of bowel wont cause any problems with the normal working of the bowel.

The urine will then be collected in a flat, watertight bag is placed over the stoma.. Special adhesive seals keep it in place. It will fill with urine in the same way as the bladder and will need to be emptied regularly.

Most people who have a urostomy live a normal life. Many return to their jobs and take up favourite pastimes again, including swimming. Learning to look after your urostomy, however, takes time and patience and no one will expect you to cope straightaway.One member of your care team will be a specialist nurse, called a stoma nurse, who will teach you how to look after your urostomy and help you through any problems. Once you are home you will still be able to  contact the stoma care nurse in the hospital, or sometimes they can visit you at home, if you need advice.

Category: BLADDER CANCER

In recent years doctors have been looking at the possibility of giving chemotherapy before surgery for a number of different types of cancer, including bladder cancer. This way of using chemotherapy is called neoadjuvant therapy.

There are two reasons for giving neoadjuvant chemotherapy for bladder cancer. The first is to try and kill off any microscopic seedlings of tumour which might have spread outside the bladder and so increase the chance of a cure. The second is to try and shrink the cancer and make the operation easier, possibly even avoiding the need for complete removal of the bladder.

A number of trials have looked at whether neoadjuvant chemotherapy before bladder removal(called a cystectomy) improves cure rates. Recent trials have shown that giving a combination of chemotherapy drugs which includes a platinum chemotherapy may give an additional benefit in reducing the recurrence of bladder cancer and in improving cure rates.. However, neoadjuvant chemotherapy has not become standard practice before cystectomy for bladder cancer, but may still be given in individual circumstances as part of a clinical trial.

You may find it helpful to discuss this with your specialist to see whether chemotherapy may be suitable in your situation.Whether or not neoadjuvant chemotherapy reduces the need for complete removal of the bladder for some patients is still uncertain. This is currently being looked at in clinical  trials but it will be a number of years before we have the answer to this.

Category: BLADDER CANCER

Last year I was diagnosed as having polyps in the bladder. I was told they were pre-cancerous. I had another cystoscopy and more polyps removed three months ago but my doctors say they are coming back again and I need chemotherapy. I am worried about what this means and what the treatment may involve

Bladder cancers can be divided into two groups: superficial and invasive.

Superficial cancers account for four out of five of all bladder tumours. These growths arise from the lining of the bladder and usually look like delicate fronds of tissue projecting into the cavity of the bladder. The growths may be single or multiple. The ‘roots’ of the growths are confined to the lining of the bladder and they do not penetrate, or invade, the wall of the bladder. In about one person in seven one of these growths will eventually turn into an invasive cancer, which will begin to penetrate the wall of the bladder.

Single superficial bladder cancers can be treated by simple surgical removal at the time of a cystoscopy. Regular cystoscopies should then be carried out to check the condition of the bladder lining. If tumours come back, or if there are multiple tumours then further treatment is required. This usually takes the form of chemotherapy.

Chemotherapy for bladder cancer can be either given by putting it into the bladder or intravenously (into the vein), so that the drugs can circulate around the body in the bloodstream.

The chemotherapy for superficial bladder cancer is given directly to the lining of the bladder. A catheter is inserted through the urethra (the tube carrying urine from the bladder to the outside). The chemotherapy drug is then instilled through the catheter into the bladder and remains there for about two hours. During that time you are asked to change position at regular intervals to circulate the drug around the bladder. The procedure can usually be done as an out-patient or a day-patient at hospital. There is a little discomfort with the insertion of the catheter and the chemotherapy may cause some slight inflammation of the bladder leading to symptoms of cystitis for a while afterwards (passing urine more frequently and/or stinging or burning when passing water).

The chemotherapy is usually given weekly for six to eight weeks.

A variety of different chemotherapy drugs are used for this treatment including mitomycin, thiotepa and doxorubicin. Sometimes a preparation called BCG is used. This is actually a vaccine, more commonly given through the skin to prevent tuberculosis, but it has been proven to be effective in controlling superficial bladder cancers. Because BCG is a vaccine, it may be called immunotherapy, rather than chemotherapy. BCG has rather more side effects than the chemotherapy drugs. These include symptoms similar to a bladder infection – having to pass urine frequently, burning on passing urine and blood in the urine. People also sometimes have a fever with it, all of these effects usually settle within a day or two.

Category: BLADDER CANCER

Very often when a cancer is treated the treatment will take away all evidence of that cancer: symptoms will disappear, physical examination and special tests (like blood tests and scans) will all go back to normal. All the appearances will suggest that the problem has been cured.


But sometimes there will be microscopic traces of the cancer left behind. Because they are so tiny these traces will not cause any symptoms and they will be too small to show up on even the most careful of examinations and most sensitive of special tests. These tiny clusters of cancer cells may lie dormant for months or years but may eventually grow and the cancer may come back.

Since these minute cells that might have been left behind cannot be detected in any way it is impossible to give an absolute guarantee that a cancer has been cured after treatment.

Having said this, very many people are cured of their cancer by modern day treatment. The chances of getting a cure depend on the type of cancer that someone has, how advanced (how large it was and how far it had spread) at the time it was first discovered (this is sometimes known as the ‘stage’ of the cancer) and how well that cancer responds to treatment.

There are now masses of statistics which doctors can use as a guide to predicting the chances of a cure for any particular cancer at any particular stage. These show that for some of the more curable types of cancer the chances of the cancer coming back after treatment are very small indeed, particularly if it was discovered at an early stage. Whereas for other types or  cancers diagnosed when they were more advanced, the outcome is likely to be poorer.

These figures are only ‘statistics’ which means they cannot absolutely predict what will happen to an individual but they do give a good idea of the ‘chances’ of whether, or not, someone will be cured. So doctors rely on these figures for deciding what the likely outcome is for each person at the end of their treatment.

These days many many people are cured of their cancers. So if your doctors have given you the ‘all clear’, although there is no absolute way of proving they are right and guaranteeing you are cured, they obviously think your chances of success are excellent and you should look forward to the future with confidence.

The short answer to this is, yes. Many people are cured of their cancers – but unfortunately some are not.

There are three important factors which affect the chance of having a cure: the type of cancer, how ‘advanced’ that cancer is when it is discovered, and how well the cancer responds to treatment.

Cancer is not a single disease. There are hundreds of different types of cancer and each of these different types has different chances of cure. So, for example, cures are very common in conditions like breast cancer, bowel cancer, testicular cancer, skin cancer and Hodgkin’s disease, but they are much less common in cancers of the  lung, pancreas and stomach.

For any one type of cancer, a tumour that is diagnosed when it is small and has not spread at all will always have a better chance of a cure than one that is only discovered when it is more advanced, and has grown to a large size and sent seedlings, called secondary cancers, to other parts of the body. So, for example, a bowel cancer that has not spread beyond the lining of the wall of the bowel is usually completely cured by an operation whereas a bowel cancer that is only found when it has already sent seedlings to the liver is only rarely curable. On the other hand, with cancers that are very sensitive to treatment, such as Hodgkin’s disease or testicular cancer, most people can still be cured even when the cancer has developed widespread secondaries.

It is important to mention that modern cancer treatments are also improving cure rates. Many kinds of cancer that were almost always incurable fifty years ago are now routinely cured by modern day therapies.

Category: BLADDER CANCER

Bladder cancer makes up about 1 in every 25 cancers and is almost three times  more commonin men than women. About 11,000 people in the UKare diagnosed with bladder cancer each year. Bladder cancer occurs most commonly between the ages of 50 and 70. Bladder cancer is rare in men and women below the age of 40.

Smoking increases the risk of getting bladder cancer.

The main symptom of cancer of the bladder is blood in the urine(haematuria). Most people with bladder cancer notice this as their first symptom. In some cases haematuria may not be visible to the naked eye, and a simple urine test can help detect this.Other less common symptoms include persistent burning or having to pass urine more frequently but these symptoms are more likely to be caused by bladder irritation or infection rather than cancer or in a man due to their prostate being enlarged.

The Department of Health has given guidelines to family doctors (GPs) suggesting they should arrange an urgent appointment with a specialist in bladder disease (called a urologist) to check for anyone who comes with either of the following problems: 

  • you have blood in your urine
  • you are over 50 and your GP detects tiny amounts of blood in your urine

There are many other causes other than cancer which can cause haematuria,  however if you do notice that your are passing blood you should see your GP who can discuss this with you and, if they think it is necessary, arrange an appointment with a specialist to be on the safe side.

Category: BLADDER CANCER

Despite the advances that have been made in the treatment of cancer there are still many tumours that cannot be cured. In these situations it often possible for different treatments to stop the growth and spread of the cancer, or even to shrink  it for a period of time.

Depending on the type of cancer and treatment which has been given this period of time when the tumour is no longer growing may last from a few weeks to a number of years.During this time the tumour is said to be  under control or ‘stable’. 

Other phrases which are sometimes used to describe this situation are ‘static disease’ and ‘ISQ’ (in status quo). If the cancer has shrunk  by at least 50% before the period of ‘stabilisation’ this may be referred to as a ‘partial remission’ or ‘partial regression’ or ‘partial response’ (all three terms mean the same thing).

Small changes in tumour size, either recorded by direct measurement or by looking at images on x-rays or scans are difficult to assess precisely. Therefore there is general agreement among cancer specialists that in order for a cancer to show signs of progression, or a relapse, there must be a greater than 25% change in the measurements that have been used to assess it. So provided that any change is less then this level, and assuming there has been no other evidence to suggest the disease is becoming active again), then the condition will still recorded as being ‘stable’.

The urethra is the tube which links the bladder to the penis in men or the vulva in women. This means that surgeons can pass a tube, called a cystoscope. through the urethra into the bladder. Instruments can then be passed through the cystoscope and used to snip off the tumour and, using a probe carrying a high frequency electric current, can cauterize (burn) the area to prevent excessive bleeding. This operation is called a transurethral resection of the bladder tumour or TURBT. Sometimes the probe is used simply to burn off the tumour, rather than cutting it away, and this is known as a cystodiathermy.

Both TURBT and cystodiathermy are simple operations but they do need an anaesthetic and a stay of a day or two in hospital.

TURBT, or csytodiathermy, are used to treat superficial bladder cancers (tumours which are confined to the lining of the bladder and don’t penetrate, or invade, more deeply into the muscle of the bladder). These superficial tumours account for about 8 out of 10 of all bladder cancers.

After this treatment, follow-up cystoscopies (examinations of the bladder through the cystoscope) are needed at regular intervals (usually every three to four months at first) because the tumours can often come back. Most follow-up cystoscopies can be done in the out-patient department under a local anaesthetic. If there is any recurrence of the cancer the tumours can usually be surgically removed (by a further TURBP or cystodiathermy) while there still at an early stage.

Category: BLADDER CANCER

When someone has incurable cancer it is very natural that their relatives want to know how long they might live for (even if the patient themselves does not want to know) so that they can plan and start to come to terms with a distressing situation.

Unfortunately it is usually difficult, even for the most experienced cancer specialist, to give an accurate answer. This is because every patient is a unique individual and will be affected differently by their illness. Even two people of the same age, with the same type of cancer, which has spread to the same extent, can have very different survival times. This can happen because many other things influence survival including general fitness, will power, the response to treatment and the development (or avoidance) of unexpected complications.

Despite all this, if the doctor knows the type of cancer and how far it has spread then they will be able to offer ‘average’ figures for life expectancy. But, very importantly, these are only averages. This means that some people will live a little longer, and a few will live a lot longer, than predicted, whilst others will survive a shorter time.

So, in many ways, even an expert opinion of life expectancy for any individual patient is little more than informed guess.

Sometimes, however, even if doctors explain the uncertainties, patients and their relatives will still put great faith in the time they have been given. This can then lead to problems if things go down hill more quickly (and sometimes there are even difficulties if people live much longer than expected).

Because of this uncertainty some doctors are reluctant to offer survival times to their patients (or to relatives). Most specialists, however, will be prepared to discuss the issue, realising that people do need some idea of time scales in order to plan their lives and cope with things. But their advice is still only a guide to what might happen and not a precise forecast of what will happen. .

Category: BLADDER CANCER

In recent years there have been a great many studies looking at the effects of exercise and the likelihood of developing cancer.

There is now good evidence that people who are physically active do have a lower risk of developing cancer of the colon (part of the bowel) and cancer of the breast. For colon cancer, where the evidence is strongest, it has been suggested that people whose life includes some moderate exercise have half the risk of developing the cancer compared to those lead an entirely sedentary existence.

For a number of other cancers, including prostate cancer, cancer of the womb and testicular cancer, the figures are less certain with some reports showing exercise is beneficial and others showing no difference.

In over 200 reports, however, there have been none suggesting that exercise increases cancer risk. So as moderate exercise is good for us anyway, reducing the risk of conditions like heart disease and diabetes, it makes sense to keep active.

Category: BLADDER CANCER

As a result of  recent clinical trials a number of chemotherapy combinations have been found to be active in bladder cancer. Until recently the best chemotherapy for advanced bladder cancer was regarded to be a treatment called M-VAC. This is a combination of four different chemotherapy drugs: methotrexate, vincristine, adriamycin (also known as doxorubicin) and cisplatin. Recent trials of new drugs such as gemcitabine and taxol in combination with cisplatinor carboplatin suggest that these combinations may be at least as effective as MVAC and  have less side effects. 

 In clinical trials about half the patients who have received one of these regimes had a benefit. This benefit consisted of shrinkage of the tumour or control of the cancer for a period of time but, unfortunately, did not bring about a cure.

These chemotherapy regimes, particularly MVAC, have  a number of side effects, some of which can be quite severe. These include damage to the kidneys, a high risk of infections, hearing impairment, a sore mouth and hair loss. Fortunately, most of these side effects can be reduced with the use of medication given at the same time as the chemotherapy.

Bladder cancer often occurs in elderly people who are more likely to have other medical problems apart from their cancer. Generally this means that they may not be able to tolerate the treatment as well as someone who is younger and fitter, and therefore may experience more side effects.

So chemotherapy may be an option for some people with advanced bladder cancer but the benefits are limited and have to be balanced against the side effects from the treatment. Your father may find it helpful to talk this through with his specialist to see if chemotherapy might be an option for him.

Category: BLADDER CANCER

If a bladder cancer is present it will often lead to some blood in the urine, although this may not be apparent to the naked eye. Bladder cancers may also shed cells which can appear in the urine. This means that urine can be tested for either traces of blood or the presence of cancer cells. Unfortunately, neither of these tests have been particularly helpful in diagnosing bladder cancer, as blood in the urine can be due to a number of reasons (such as a urine infection) and is not specific enough to help detect a cancer. A test looking for cancer cells in the urine is known as urine cytology. If  cancer cells are seen this usually means that a bladder cancer is present. However, the test is negative for the majority of early bladder cancers, and even  with more advanced cancers only about 3 out of 4 will be detected in this way. As a negative cytology test does not rule out the presence of a bladder cancer it is not a reliable diagnostic test.

There are several testing kits that are available over the counter in shops, however they aren’t used widely because they aren’t very sensitive or specific to bladder cancer. If you are concerned that you may have bladder cancer do speak with your doctor.

Recently doctors in the UK have developed a new urine test which may help detect bladder cancer at an earlier stage, and reduce the need for examinations such as a cystoscopy (examining the bladder with a small telescope). This urine test measures the levels of a protein called Mcm5 which has been found to be  higher in someone with bladder cancer. This test is currently being tested in a trial in the UK to find out if it is as effective as examining the bladder with a cytsopscope. This trial will take a few years to complete, so until these results are known, cystoscopy is still the most effective test to detect bladder cancer.

Category: BLADDER CANCER

There are many causes for blood in the urine(called haematuria). Often this symptom is due to problems like infections but it can sometimes be a sign of acancer. So this symptom should never be ignored. Your mother should arrange to see her family doctor (GP) for a check up as soon as she can to find the cause. The GP  is likely to do a simple test on a sample of her urine which can detect  even traces of blood in the urine which may not be visible to the naked eye.

The Department of Health has given guidelines to GP’s suggesting they should arrange an urgent appointment with a specialist (called a urologist) to check for anyone who  has either of the following problems:

  • passing blood in their urine
  • someone who is over 50 and when their urine is tested there are traces of blood present, even though these are not visible.

An urgent hospital appointment usually means that the specialist will see your mother within two weeks.

When your mother sees the specialist they will take a full medical history and examine her. Depending on what the specialist findsthere may be more specialised tests carried out, to help them diagnosis the cause. These tests may include:

  • blood tests
  • a cystoscopy, ( a small flexible telescope) helps the specialist to look at the bladder and the tube from the bladder to the outside (the urethra). If anything abnormal is seen then they will take tiny samples of tissue (biopsies) to look at under the microscope. This is usually done under a general anaesthetic
  • an IVU or IVP,( a special x-ray which uses a dye injected into a vein in the arm), to show up the kidneys, the ureters (the tubes joining the kidneys to the bladder) and the bladder.
  • a CT scan, which uses x-rays to build up a three dimensional picture of the structures in the body
  • an ultrasound scan, which uses sound waves to build up pictures of the structures of the body.

If these tests show that your mother does have a cancer then  any treatment will depend on several factors including the type of bladder cancer as well as the stage(how deeply the cancer is affecting the lining of the bladder) and grade( how quickly growing the cells are). Treatment  commonly involves an operation to remove the growth, or sometimes radiotherapy or occasionally chemotherapy may be given.

Category: BLADDER CANCER

The cystoscopy examination uses a  small telescope(the cystoscope) that allows doctors to look at the lining of the bladder. During the examination they can also take samples of any abnormal looking tissue for examination under the microscope (called a biopsy).

Although this test has confirmed that your husband has bladder cancer the cystoscopy will only have looked  at the surface of the bladder and will not have given information about whether the cancer may (or may not) has spread into the musclewall of the bladder, or surrounding tissue in the pelvis.

In order to decide the best treatment for bladder cancer it is important to know whether the cancer is within the bladder or if  it  has spread through the wall of the bladder to surrounding tissues.  The scan can help the doctors to see the extent of the cancer and help them decide the best treatment. The types of scans used can either be  a CT scan or an MRI scan. Both scans use special machines to take a series of pictures of the pelvis which produce a detailed image of the inside of the body.

Both scans involve having an injection of a dye into a vein to help show up the bladder and surrounding structures.and can be done as an out-patient (taking less than one hour). As with all medical tests the scans are not always 100 per cent accurate but they do give valuable additional information about the size and extent of the cancer.

Category: BLADDER CANCER

In the early days of radiotherapy treatment, skin burns during treatment and sometimes permanent damage or scarring of the skin, was common.

This changed during the late 1950s and 1960s as two new types of machine were introduced to give the radiotherapy treatment. These are called Linear Accelerators and Cobalt Units. These machines produce irradiating rays of a much greater energy than the previous machines. This higher energy of the rays give the treatments greater accuracy and greater penetration of the tissues (allowing treatment of cancers deep inside the body and also reduce skin damage. This is because the high energy rays pass through the first centimetre or two of the first tissue they meet, before they actually begin to give out any radiation.
 
Skin problems are uncommon with modern radiotherapy treatment. Occasionally skin problems can occur because of the location of the cancer and the area of the body treated. Usually this will cause no more than some temporary pinkness or redness of the skin for a week or two after treatment. If any soreness does develop it will only last a short time and can usually be eased with creams or lotions, which you will be given at the hospital. Severe or permanent skin damage is  rare indeed.

The fact that skin damage was common forty or fifty years ago means that people can remember friends or relatives who had bad experiences with their radiotherapy treatments which  probably account for the stories you have heard. Nowadays the situation is very different and things have improved enormously.

Radiotherapy is almost always a local treatment, limited to a particular part of the body. Only the skin in that area will be irradiated and the skin elsewhere will not be affected.

The doses of radiotherapy used can vary but even with quite high doses modern radiotherapy machines usually cause a little skin irritation. Even so this does mean that the skin which has been irradiated will be more sensitive to sunlight than your normal skin.

The degree of sensitivity will vary from person to person. The increased sensitivity also reduces gradually with time but probably never disappears completely.

Having had radiotherapy does not mean you must avoid the sun completely but you should take care over exposing the treated skin. It is very important to cover the treated area for at least the first year after radiotherapy. Wear clothing made of cotton or natural fibres which have a closer weave and offer more protection against the sun. Even after this time the area treated will be more delicate, so extra care should be given. You should also use a high factor sunscreen (of at least factor 15). Remember, too much sunbathing does carry the risk of leading to skin cancer and should be avoided.

Very occasionally radiotherapy is given to the whole body. In this situation the doses are normally quite low but you should still take precautions in exposure to strong sunlight. Seek advice  from your doctors if you are having this type of treatment.

When a new drug is being considered as a treatment for cancer it has to go through many tests to make sure it is both safe and of benefit.

If tests in the laboratory (known as preclinical testing) have been promising then the drug can be tested in people (this is clinical testing, or clinical trials). These trials follow a set pattern through various Phases, from Phase I to Phase III or IV.

A Phase I trial simply looks at the side-effects and dose of the drug in order to work out a safe way of using it.

If the Phase I trial is successful then Phase II trials can be begin. The Phase II trials are intended to see whether the drug might be effective as a treatment against cancer.

The usual pattern for Phase II trials is for the new drug to be given to groups of people with different types of advanced cancer. Because the drug is new, and its benefits are unknown, it is usually only people who have cancers which are no longer controlled by conventional treatment who are considered for Phase II studies (since it would be wrong to give someone a treatment of uncertain value, even if it is new, when there are tried and tested treatments already available which could be helpful).

For each type of cancer which it is tested against, the new drug is initially given to about 15 to 20 people. If some of those people show an improvement as a result of having the drug then more people with that particular type of cancer will be tested to try and get a more accurate idea of how active the drug is. In this way doctors can decide whether the drug is likely to be useful and also decide which cancers are most likely to be controlled by the new treatment.

Unfortunately only a minority new drugs which reach the Phase II stage prove to be of value in cancer treatment. This means that taking part in a Phase II trial does not guarantee any benefit in terms of tumour control, and increased life expectancy. In fact it could involve a lot of extra inconvenience (with hospital visits and regular check-ups) and possible side effects from the treatment. So the chances of getting a further remission by taking part in a Phase II trial are usually quite small. Many people with advanced cancer do volunteer for these studies, partly in the hope that they may get a benefit and also to help medical science and possibly benefit other people in the future.

Another word of caution is that Phase II trials often get misreported by the media (who are always anxious for a new story about cancer). Newspaper articles, TV programmes or internet pages will often suggest that these studies are a ‘breakthrough’ or are using a ‘wonder drug’ and so, understandably, people think the drug is far more promising than is the case.

No. Diabetes is a common condition and surgeons are used  to operating regularly on people who are diabetic. Usually they will put up a drip, into a vein in the arm or back of the hand, before the operation. This will then be used to give insulin and sugar solutions to keep your blood sugar at the correct level throughout the operation and will continue until you can eat and drink normally. Throughout this time your blood sugar level will be regularly checked and the drip adjusted as necessary. This means it will be perfectly safe for you to go ahead with the surgery that you need.

Understandably, ‘nothing more to be done’ is a phrase that can cause alarm, despondency and despair. So it is important to be clear just what this means. It isn’t the end of care and support for your relative. What it does mean is that their specialists do not think there is any treatment left that has a reasonable chance of actually controlling the cancer. There is no further ‘active’ treatment, that is treatment which is given to contain or reduce the cancer, that they can usefully offer.

This decision will change the emphasis of your relative’s medical care from ‘active treatment’ to ‘supportive care’. Their GP, Macmillan nurses and the team from the local hospice team will become more involved and you may find that the hospital will play a smaller part than before.

The emphasis of care is attention to easing, and preventing, upsetting symptoms of the cancer and giving practical support, both physically and emotionally, to your relative and the family. Quality of life will become most important and, perhaps surprisingly, people with advanced cancer often find that at this late stage of their illness their quality and enjoyment of life can actually improve.

Part of this improvement can be because they no longer have the inconvenience of regular hospital visits and tests and the physical effort and burden this may involve when faced with an advanced cancer. Less disruption to a person’s daily life, and not having to cope with the often unpleasant side effects of treatment can be a benefit, particularly if the treatment is not helping to control the cancer.
 

It is natural to feel despair when the specialists say there is nothing more that can be done. So your question is one that is frequently asked. Very often, however, it is asked by relatives and not by the person who actually has the cancer. Sometimes this is because that person has come to terms with their condition and is quite willing, and possibly even relieved, to go along with the change in their care. At the same time their relatives, with the best of intentions, still feel they shouldn’t ‘give up’ and that ‘something must be done’. If your relative is still looking for active treatment there are two things they can do.

The first is for your relative to talk to their specialist (a phone call to his or her secretary should easily arrange this). They can ask about any experimental treatments and clinical trials that may be suitable. It may be that they will say there really is nothing to be offered or they may tell them about new or experimental treatments which are being tested at another hospital and might offer to refer your mother there for advice.

There are always new drugs and treatments being tested for cancer, unfortunately many of these do not prove to be successful or the benefits are likely to be small. Despite this reality, many new experimental treatments do get enthusiastic reports in the media, which all too often raise false hopes for patients and their families. Sadly this happens frequently.

However having active treatment helps some people feel positive and hopeful even though they know the chances of benefit are small. People sometimes find it easier to cope if they feel they are doing something active to try and treat the cancer, and many people are also happy to be contributing to the advancement of knowledge about cancer and its treatment. The downside is the disruption, and possible distress, from treatment and its side effects that your relative might have to go through. Also, even when there is a response to these treatments it is, at best, usually a matter of prolonging life by a few weeks or months.

If your relative doesn’t want to see the specialist, or if they feel the interview was not satisfactory, then the second thing you or they can do is ask the consultant or GP to arrange a second opinion from a consultant at another hospital. Doctors are usually happy to do this, as they appreciate a persons need to find any available treatment that may help. Even if you do this, however, it is likely that the new specialist will not be able to offer anything more. But at least you will then know that they have explored every possible avenue for their future care.

When someone has incurable cancer it is very natural that their relatives want to know how long they might live for (even if the patient themselves does not want to know) so that they can plan and start to come to terms with such a distressing situation.

Unfortunately it is usually difficult, even for the most experienced cancer specialist, to give an accurate answer. This is because every patient is a unique individual and will be affected differently by their illness. Even two people of the same age, with the same type of cancer, which has spread to the same extent, can have very different survival times. This can happen because many other things influence survival including general fitness, will power, the response to treatment and the development (or avoidance) of unexpected complications.

Despite all this, if the doctor knows the type of cancer and how far it has spread then they will be able to offer ‘average’ figures for life expectancy. But, very importantly, these are only averages. This means that some people will live a little longer, and a few will live a lot longer, than predicted, whilst others may survive a shorter time.

So, in many ways, even an expert opinion of life expectancy for any individual patient is little more than informed guess.

Sometimes, however, even if doctors explain the uncertainties, patients and their relatives will still put great faith in the time they have been given. (This can then lead to problems if someone deteriorates sooner than expected).

Because of this uncertainty some doctors are reluctant to offer survival times to their patients (or to relatives). Most specialists, however, will be prepared to discuss the issue, realising that people do need some idea of time scales in order to plan their lives and cope with things. But their advice is still only a guide to what might happen and not a precise forecast of what will happen.

Load More

1000caloriesdiet.com