MyMedExpert Health Articles

Introduction
This patient summary on loss, grief, and bereavement is adapted from the summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. The passage from the final stage of cancer to the death of a loved one is different for everyone. This summary describes loss, grief, and bereavement; the stages of grief; and methods for coping with grief. This summary also includes sections on children and grief.

 

Overview
People cope with the loss of a loved one in many ways. For some, the experience may lead to personal growth, even though it is a difficult and trying time. There is no right way of coping with death. The way a person grieves depends on the personality of that person and the relationship with the person who has died. How a person copes with grief is affected by their experience with cancer, the way the disease progressed, the person’s cultural and religious background, coping skills, mental history, support systems, and the person’s social and financial status.

The terms grief, bereavement, and mourning are often used in place of each other, but they have different meanings.

Grief is the normal process of reacting to the loss. Grief reactions may be felt in response to physical losses (for example, a death) or in response to symbolic or social losses (for example, divorce or loss of a job). Each type of loss means the person has had something taken away. As a family goes through a cancer illness, many losses are experienced, and each triggers its own grief reaction. Grief may be experienced as a mental, physical, social, or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness, and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems, or illness. Social reactions can include feelings about taking care of others in the family, seeing family or friends, or returning to work. As with bereavement, grief processes depend on the relationship with the person who died, the situation surrounding the death, and the person’s attachment to the person who died. Grief may be described as the presence of physical problems, constant thoughts of the person who died, guilt, hostility, and a change in the way one normally acts.

Bereavement is the period after a loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

Mourning is the process by which people adapt to a loss. Mourning is also influenced by cultural customs, rituals, and society’s rules for coping with loss.

Grief work includes the processes that a mourner needs to complete before resuming daily life. These processes include separating from the person who died, readjusting to a world without him or her, and forming new relationships. To separate from the person who died, a person must find another way to redirect the emotional energy that was given to the loved one. This does not mean the person was not loved or should be forgotten, but that the mourner needs to turn to others for emotional satisfaction. The mourner’s roles, identity, and skills may need to change to readjust to living in a world without the person who died. The mourner must give other people or activities the emotional energy that was once given to the person who died in order to redirect emotional energy.

People who are grieving often feel extremely tired because the process of grieving usually requires physical and emotional energy. The grief they are feeling is not just for the person who died, but also for the unfulfilled wishes and plans for the relationship with the person. Death often reminds people of past losses or separations. Mourning may be described as having the following 3 phases:

The urge to bring back the person who died.
Disorganization and sadness.
Reorganization.
Phases of a Life-Threatening Illness
Understanding how other people cope with a life-threatening illness may help the patient and his or her family prepare to cope with their own illness. A life-threatening illness may be described as having the following 4 phases:

Phase before the diagnosis.
The acute phase.
The chronic phase.
Recovery or death.
The phase before the diagnosis of a life-threatening illness is the period of time just before the diagnosis when a person realizes that he or she may develop an illness. This phase is not usually a single moment, but extends throughout the period when the person has a physical examination, including various tests, and ends when the person is told of the diagnosis.

The acute phase occurs at the time of the diagnosis when a person is forced to understand the diagnosis and make decisions about his or her medical care.

The chronic phase is the period of time between the diagnosis and the result of treatment. It is the period when a patient tries to cope with the demands of life while also undergoing treatment and coping with the side effects of treatment. In the past, the period between a cancer diagnosis and death usually lasted only a few months, and this time was usually spent in the hospital. Today, people can live for years after being diagnosed with cancer.

In the recovery phase, people cope with the mental, social, physical, religious, and financial effects of cancer.

The final (terminal) phase of a life-threatening illness occurs when death is likely. The focus changes from curing the illness or prolonging life, to providing comfort and relief from pain. Religious concerns are often the focus during this time.

 

The Pathway to Death
People who are dying may move towards death over longer or shorter periods of time and in different ways. Different causes of death result in different paths toward death.

The pathway to death may be long and slow, sometimes lasting years, or it may be a rapid fall towards death (for example, after a car accident) when the chronic phase of the illness, if it exists at all, is short. The peaks and valleys pathway describes the patient who repeatedly gets better and then worse again (for example, a patient with AIDS or leukemia). Another pathway to death may be described as a long, slow period of failing health and then a period of stable health (for example, patients whose health gets worse and then stabilizes at a new, more limiting level). Patients on this pathway must readjust to losses in functioning ability.

Deaths from cancer often occur over a long period of time, and may involve long-term pain and suffering, and/or loss of control over one’s body or mind. Deaths caused by cancer are likely to drain patients and families physically and emotionally because they occur over a long period of time.

 

Anticipatory Grief
Anticipatory grief is the normal mourning that occurs when a patient or family is expecting a death. Anticipatory grief has many of the same symptoms as those experienced after a death has occurred. It includes all of the thinking, feeling, cultural, and social reactions to an expected death that are felt by the patient and family.

Anticipatory grief includes depression, extreme concern for the dying person, preparing for the death, and adjusting to changes caused by the death. Anticipatory grief gives the family more time to slowly get used to the reality of the loss. People are able to complete unfinished business with the dying person (for example, saying “good-bye,” “I love you,” or “I forgive you”).

Anticipatory grief may not always occur. Anticipatory grief does not mean that before the death, a person feels the same kind of grief as the grief felt after a death. There is not a set amount of grief that a person will feel. The grief experienced before a death does not make the grief after the death last a shorter amount of time.

Grief that follows an unplanned death is different from anticipatory grief. Unplanned loss may overwhelm the coping abilities of a person, making normal functioning impossible. Mourners may not be able to realize the total impact of their loss. Even though the person recognizes that the loss occurred, he or she may not be able to accept the loss mentally and emotionally. Following an unexpected death, the mourner may feel that the world no longer has order and does not make sense.

Some people believe that anticipatory grief is rare. To accept a loved one’s death while he or she is still alive may leave the mourner feeling that the dying patient has been abandoned. Expecting the loss often makes the attachment to the dying person stronger. Although anticipatory grief may help the family, the dying person may experience too much grief, causing the patient to become withdrawn.

 

Phases of Grief
The process of bereavement may be described as having 4 phases:

Shock and numbness: Family members find it difficult to believe the death; they feel stunned and numb.
Yearning and searching: Survivors experience separation anxiety and cannot accept the reality of the loss. They try to find and bring back the lost person and feel ongoing frustration and disappointment when this is not possible.
Disorganization and despair: Family members feel depressed and find it difficult to plan for the future. They are easily distracted and have difficulty concentrating and focusing.
Reorganization.
Treatment
Most of the support that people receive after a loss comes from friends and family. Doctors and nurses may also be a source of support. For people who experience difficulty in coping with their loss, grief counseling or grief therapy may be necessary.

Grief counseling helps mourners with normal grief reactions work through the tasks of grieving. Grief counseling can be provided by professionally trained people, or in self-help groups where bereaved people help other bereaved people. All of these services may be available in individual or group settings.

The goals of grief counseling include:

Helping the bereaved to accept the loss by helping him or her to talk about the loss.
Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt, anxiety, helplessness, and sadness).
Helping the bereaved to live without the person who died and to make decisions alone.
Helping the bereaved to separate emotionally from the person who died and to begin new relationships.
Providing support and time to focus on grieving at important times such as birthdays and anniversaries.
Describing normal grieving and the differences in grieving among individuals.
Providing continuous support.
Helping the bereaved to understand his or her methods of coping.
Identifying coping problems the bereaved may have and making recommendations for professional grief therapy.
Grief therapy is used with people who have more serious grief reactions. The goal of grief therapy is to identify and solve problems the mourner may have in separating from the person who died. When separation difficulties occur, they may appear as physical or behavior problems, delayed or extreme mourning, conflicted or extended grief, or unexpected mourning (although this is seldom present with cancer deaths).

Grief therapy may be available as individual or group therapy. A contract is set up with the individual that establishes the time limit of the therapy, the fees, the goals, and the focus of the therapy.

In grief therapy, the mourner talks about the deceased and tries to recognize whether he or she is experiencing an expected amount of emotion about the death. Grief therapy may allow the mourner to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.

Human beings tend to make strong bonds of affection or attachment with others. When these bonds are broken, as in death, a strong emotional reaction occurs. After a loss occurs, a person must accomplish certain tasks to complete the process of grief. These basic tasks of mourning include accepting that the loss happened, living with and feeling the physical and emotional pain of grief, adjusting to life without the loved one, and emotionally separating from the loved one and going on with life without him or her. It is important that these tasks are completed before mourning can end.

In grief therapy, 6 tasks may be used to help a mourner work through grief:

Develop the ability to experience, express, and adjust to painful grief-related changes.
Find effective ways to cope with painful changes.
Establish a continuing relationship with the person who died.
Stay healthy and keep functioning.
Re-establish relationships and understand that others may have difficulty empathizing with the grief they experience.
Develop a healthy image of oneself and the world.
Complications in grief may come about due to uncompleted grief from earlier losses. The grief for these earlier losses must be managed in order to handle the current grief. Grief therapy includes dealing with the blockages to the mourning process, identifying unfinished business with the deceased, and identifying other losses that result from the death. The bereaved is helped to see that the loss is final and to picture life after the grief period.

 

Complicated Grief
Complicated grief reactions require more complex therapies than uncomplicated grief reactions. Adjustment disorders (especially depressed and anxious mood or disturbed emotions and behavior), major depression, substance abuse, and even post-traumatic stress disorder are some of the common problems of complicated bereavement. Complicated grief is identified by the extended length of time of the symptoms, the interference caused by the symptoms, or by the intensity of the symptoms (for example, intense suicidal thoughts or acts).

Complicated or unresolved grief may appear as a complete absence of grief and mourning, an ongoing inability to experience normal grief reactions, delayed grief, conflicted grief, or chronic grief. Factors that contribute to the chance that one may experience complicated grief include the suddenness of the death, the gender of the person in mourning, and the relationship to the deceased (for example, an intense, extremely close, or very contradictory relationship). Grief reactions that turn into major depression should be treated with both drug and psychological therapy. One who avoids any reminders of the person who died, who constantly thinks or dreams about the person who died, and who gets scared and panics easily at any reminders of the person who died may be suffering from post-traumatic stress disorder. Substance abuse may occur, frequently in an attempt to avoid painful feelings about the loss and symptoms (such as sleeplessness), and can also be treated with drugs and psychological therapy.

 

Children and Grief
In the past, children were thought to be miniature adults and were expected to behave as adults. It is now understood that there are differences in the ways in which children and adults mourn.

Unlike adults, bereaved children do not experience continual and intense emotional and behavioral grief reactions. Children may seem to show grief only occasionally and briefly, but in reality a child’s grief usually lasts longer than that of an adult. This may be explained by the fact that a child’s ability to experience intense emotions is limited. Mourning in children may need to be addressed again and again as the child gets older. Since bereavement is a process that continues over time, children will think about the loss repeatedly, especially during important times in their life, such as going to camp, graduating from school, getting married, or giving birth to their own children.

A child’s grief may be influenced by his or her age, personality, stage of development, earlier experiences with death, and his or her relationship with the deceased. The surroundings, cause of death, family members’ ability to communicate with one another and to continue as a family after the death can also affect grief. The child’s ongoing need for care, the child’s opportunity to share his or her feelings and memories, the parent’s ability to cope with stress, and the child’s steady relationships with other adults are also other factors that may influence grief.

Children do not react to loss in the same ways as adults. Grieving children may not show their feelings as openly as adults. Grieving children may not withdraw and dwell on the person who died, but instead may throw themselves into activities (for example, they may be sad one minute and playful the next). Often families think the child doesn’t really understand or has gotten over the death. Neither is true; children’s minds protect them from what is too powerful for them to handle. Children’s grieving periods are shortened because they cannot think through their thoughts and feelings like adults. Also, children have trouble putting their feelings about grief into words. Instead, his or her behavior speaks for the child. Strong feelings of anger and fears of abandonment or death may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and anxieties. These games are familiar to the children and provide safe opportunities to express their feelings.

Children’s Grief and Developmental Stages
Children at different stages of development have different understandings of death and the events near death.

Infants
Infants do not recognize death, but feelings of loss and separation are part of developing an awareness of death. Children who have been separated from their mother may be sluggish, quiet, unresponsive to a smile or a coo, undergo physical changes (for example, weight loss), be less active, and sleep less.

Age 2-3 years
Children at this age often confuse death with sleep and may experience anxiety as early as age 3. They may stop talking and appear to feel overall distress.

Age 3-6 years
At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though he or she might have been buried, and ask questions about the deceased (for example, how does the deceased eat, go to the toilet, breathe, or play?). Young children know that death occurs physically, but think it is temporary, reversible, and not final. The child’s concept of death may involve magical thinking. For example, the child may think that his or her thoughts can cause another person to become sick or die. Grieving children under 5 may have trouble eating, sleeping, and controlling bladder and bowel functions.

Age 6-9 years
Children at this age are commonly very curious about death, and may ask questions about what happens to one’s body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel of death, or bogeyman. They may see death as final and frightening but as something that happens mostly to old people (and not to themselves). Grieving children can become afraid of school, have learning problems, develop antisocial or aggressive behaviors, become overly concerned about their own health (for example, developing symptoms of imaginary illness), or withdraw from others. Or, children this age can become too attached and clinging. Boys usually become more aggressive and destructive (for example, acting out in school), instead of openly showing their sadness. When a parent dies children may feel abandoned by both their deceased parent and their surviving parent because the surviving parent is grieving and is unable to emotionally support the child.

Ages 9 and older
By the time a child is 9 years old, death is known to be unavoidable and is not seen as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.

Grief and Developmental Stages
Enlarge  Age    Understanding of Death    Expressions of Grief   
Infancy to 2 years Is not yet able to understand death. Quietness, crankiness, decreased activity, poor sleep, and weight loss.
Separation from mother causes changes. 
2-6 years Death is like sleeping. Asks many questions (How does she go to the bathroom? How does she eat?).
Problems in eating, sleeping, and bladder and bowel control.
Fear of abandonment.
Tantrums.
Dead person continues to live and function in some ways. Magical thinking (Did I think something or do something that caused the death? Like when I said I hate you and I wish you would die?).
Death is temporary, not final.
Dead person can come back to life.
6-9 years Death is thought of as a person or spirit (skeleton, ghost, bogeyman).  Curious about death.
Asks specific questions.
May have exaggerated fears about school.
Death is final and frightening.  May have aggressive behaviors (especially boys).
Some concerns about imaginary illnesses.
Death happens to others, it won’t happen to ME. May feel abandoned.
9 and older Everyone will die.  Heightened emotions, guilt, anger, shame.
Increased anxiety over own death.
Mood swings.
Death is final and cannot be changed. Fear of rejection; not wanting to be different from peers.
Even I will die. Changes in eating habits.
Sleeping problems.
Regressive behaviors (loss of interest in outside activities). 
Impulsive behaviors.
Feels guilty about being alive (especially related to death of a brother, sister, or peer).
In American society, many grieving adults withdraw and do not talk to others. Children, however, often talk to the people around them (even strangers) to see the reactions of others and to get clues for their own responses. Children may ask confusing questions. For example, a child may ask, “I know grandpa died, but when will he come home?” This is a way of testing reality and making sure the story of the death has not changed.

Other Issues for Grieving Children
Children’s grief expresses 3 issues:

Did I cause the death to happen?
Is it going to happen to me?
Who is going to take care of me?
Did I cause the death to happen?
Children often think that they have magical powers. If a mother says in irritation, “You’ll be the death of me” and later dies, her child may wonder if he or she actually caused the mother’s death. Also, when children argue, one may say (or think), “I wish you were dead.” Should that child die, the surviving child may think that his or her thoughts actually caused the death.

Is it going to happen to me?
The death of another child may be especially hard for a child. If the child thinks that the death may have been prevented (by either a parent or a doctor) the child may think that he or she could also die.

Who is going to take care of me?
Since children depend on parents and other adults to take care of them, a grieving child may wonder who will care for him or her after the death of an important person.

Grieving Children: Treatment
A child’s grieving process may be made easier by being open and honest with the child about death, using direct language, and incorporating the child into memorial ceremonies for the person who died.

Explanation of death
Not talking about death (which indicates that the subject is off-limits) does not help children learn to cope with loss. When discussing death with children, explanations should be simple and direct. Each child should be told the truth using as much detail as he or she is able to understand. The child’s questions should be answered honestly and directly. Children need to be reassured about their own security (they often worry that they will also die, or that their surviving parent will go away). Children’s questions should be answered, making sure that the child understands the answers.

Correct language
A discussion about death should include the proper words, such as cancer, died, and death. Substitute words or phrases (for example, “he passed away,” “he is sleeping,” or “we lost him”) should never be used because they can confuse children and lead to misunderstandings.

Planning memorial ceremonies
When a death occurs, children can and should be included in the planning and participation of memorial ceremonies. These events help children (and adults) remember loved ones. Children should not be forced to be involved in these ceremonies, but they should be encouraged to take part in those portions of the events with which they feel most comfortable. If the child wants to attend the funeral, wake, or memorial service, he or she should be given in advance a full explanation of what to expect. The surviving parent may be too involved in his or her own grief to give their child full attention, therefore, it may be helpful to have a familiar adult or family member care for the grieving child.

References and resources for grieving children
There are many helpful books and videos that can be shared with grieving children:

Worden JW: Children and Grief: When a Parent Dies. New York: The Guilford Press, 1996.
Doka KJ, Ed.: Children Mourning, Mourning Children. Washington, DC: Hospice Foundation of America, 1995.
Wass H, Corr CA: Childhood and Death. Washington, DC: Hemisphere Publishing Corporation, 1984.
Corr CA, McNeil JN: Adolescence and Death. New York: Springer Publishing Company, 1986.
Corr, CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed., Pacific Grove: Brooks/Cole Publishing Company, 1997.
Grollman EA: Talking About Death: A Dialogue Between Parent and Child. 3rd ed., Boston: Beacon Press, 1990.
Schaefer D, Lyons C: How Do We Tell The Children?: Helping Children Understand And Cope When Someone Dies. New York: Newmarket Press, 1988.
Wolfelt A: Helping Children Cope with Grief. Muncie: Accelerated Development, 1983.
Walker A: To Hell with Dying. San Diego: Harcourt Brace Jovanovich, 1988.
Williams M: Velveteen Rabbit. Garden City: Doubleday, 1922.
Viost J: The Tenth Good Thing About Barney. New York: Atheneum, 1971.
Tiffault BW: A Quilt for Elizabeth. Omaha: Centering Corporation, 1992.
Levine J: Forever in My Heart: A Story to Help Children Participate in Life as a Parent Dies. Burnsville, NC: Rainbow Connection, 1992.
Knoderer K: Memory Book: A Special Way to Remember Someone You Love. Warminster: Mar-Co Products, 1995.
de Paola T: Nana Upstairs and Nana Downstairs. New York, NY: GP Putnam’s Sons, 1973.

Culture and Response to Grief and Mourning
Grief felt for the loss of a loved one, the loss of a treasured possession, or a loss associated with an important life change, occurs across all ages and cultures. However, the role that cultural heritage plays in an individual’s experience of grief and mourning is not well understood. Attitudes, beliefs, and practices regarding death must be described according to myths and mysteries surrounding death within different cultures.

Individual, personal experiences of grief are similar in different cultures. This is true even though different cultures have different mourning ceremonies, traditions, and behaviors to express grief. Helping families cope with the death of a loved one includes showing respect for the family’s cultural heritage and encouraging them to decide how to honor the death. Important questions that should be asked of people who are dealing with the loss of a loved one include:

What are the cultural rituals for coping with dying, the deceased person’s body, the final arrangements for the body, and honoring the death?
What are the family’s beliefs about what happens after death?
What does the family feel is a normal expression of grief and the acceptance of the loss?
What does the family consider to be the roles of each family member in handling the death?
Are certain types of death less acceptable (for example, suicide), or are certain types of death especially hard to handle for that culture (for example, the death of a child)?
Death, grief, and mourning spare no one and are normal life events. All cultures have developed ways to cope with death. Interfering with these practices may interfere with the necessary grieving processes. Understanding different cultures’ response to death can help physicians recognize the grieving process in patients of other cultures.

Source: National Cancer Institute (www.cancer.gov) , National Institutes of Health

 

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What Is Melanoma?

Melanoma is a type of skin cancer. It begins in cells in the skin called melanocytes. To understand melanoma, it is helpful to know about the skin and about melanocytes—what they do, how they grow, and what happens when they become cancerous.

The Skin

The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D.

The skin has two main layers: the outer epidermis and the inner dermis.

The epidermis is mostly made up of flat, scalelike cells called squamous cells. Round cells called basal cells lie under the squamous cells in the epidermis. The lower part of the epidermis also contains melanocytes.

The dermis contains blood vessels, lymph vessels, hair follicles, and glands. Some of these glands produce sweat, which helps regulate body temperature. Other glands produce sebum, an oily substance that helps keep the skin from drying out. Sweat and sebum reach the skin’s surface through tiny openings called pores.

Melanocytes and Moles
Melanocytes produce melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes produce more pigment, causing the skin to tan, or darken.

Sometimes, clusters of melanocytes and surrounding tissue form noncancerous growths called moles. (Doctors also call a mole a nevus; the plural is nevi.) Moles are very common. Most people have between 10 and 40 moles. Moles may be pink, tan, brown, or a color that is very close to the person’s normal skin tone. People who have dark skin tend to have dark moles. Moles can be flat or raised. They are usually round or oval and smaller than a pencil eraser. They may be present at birth or may appear later on—usually before age 40. They tend to fade away in older people. When moles are surgically removed, they normally do not return.

Understanding Cancer
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor. Not all tumors are cancer.

Tumors can be benign or malignant:

Benign tumors are not cancer:

They are rarely life threatening.

Usually, benign tumors can be removed, and they seldom grow back.

Cells from benign tumors do not spread to tissues around them or to other parts of the body.

Malignant tumors are cancer:

They are generally more serious and may be life threatening.

Malignant tumors usually can be removed, but they can grow back.

Cells from malignant tumors can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells spread from the original cancer (the primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis. Different types of cancer tend to spread to different parts of the body.
Melanoma
Melanoma occurs when melanocytes (pigment cells) become malignant. Most pigment cells are in the skin; when melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma may also occur in the eye (ocular melanoma or intraocular melanoma). Rarely, melanoma may arise in the meninges, the digestive tract, lymph nodes, or other areas where melanocytes are found. Melanomas that begin in areas other than the skin are not discussed in this booklet. The Cancer Information Service (1-800-4-CANCER) can provide information about these types of melanoma.

Melanoma is one of the most common cancers. The chance of developing it increases with age, but this disease affects people of all ages. It can occur on any skin surface. In men, melanoma is often found on the trunk (the area between the shoulders and the hips) or the head and neck. In women, it often develops on the lower legs. Melanoma is rare in black people and others with dark skin. When it does develop in dark-skinned people, it tends to occur under the fingernails or toenails, or on the palms or soles.

When melanoma spreads, cancer cells may show up in nearby lymph nodes. Groups of lymph nodes are found throughout the body. Lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the lymphatic system. If the cancer has reached the lymph nodes, it may mean that cancer cells have spread to other parts of the body such as the liver, lungs, or brain. In such cases, the cancer cells in the new tumor are still melanoma cells, and the disease is called metastatic melanoma, not liver, lung, or brain cancer.
Melanoma: Who’s at Risk?
No one knows the exact causes of melanoma. Doctors can seldom explain why one person gets melanoma and another does not.

However, research has shown that people with certain risk factors are more likely than others to develop melanoma. A risk factor is anything that increases a person’s chance of developing a disease. Still, many who do get this disease have no known risk factors.

Studies have found the following risk factors for melanoma:

Dysplastic nevi: Dysplastic nevi are more likely than ordinary moles to become cancerous. Dysplastic nevi are common, and many people have a few of these abnormal moles. The risk of melanoma is greatest for people who have a large number of dysplastic nevi. The risk is especially high for people with a family history of both dysplastic nevi and melanoma.

Many (more than 50) ordinary moles: Having many moles increases the risk of developing melanoma.

Fair skin: Melanoma occurs more frequently in people who have fair skin that burns or freckles easily (these people also usually have red or blond hair and blue eyes) than in people with dark skin. White people get melanoma far more often than do black people, probably because light skin is more easily damaged by the sun.

Personal history of melanoma or skin cancer: People who have been treated for melanoma have a high risk of a second melanoma. Some people develop more than two melanomas. People who had one or more of the common skin cancers (basal cell carcinoma or squamous cell carcinoma) are at increased risk of melanoma.

Family history of melanoma: Melanoma sometimes runs in families. Having two or more close relatives who have had this disease is a risk factor. About 10 percent of all patients with melanoma have a family member with this disease. When melanoma runs in a family, all family members should be checked regularly by a doctor.

Weakened immune system: People whose immune system is weakened by certain cancers, by drugs given following organ transplantation, or by HIV are at increased risk of developing melanoma.

Severe, blistering sunburns: People who have had at least one severe, blistering sunburn as a child or teenager are at increased risk of melanoma. Because of this, doctors advise that parents protect children’s skin from the sun. Such protection may reduce the risk of melanoma later in life. Sunburns in adulthood are also a risk factor for melanoma.

Ultraviolet (UV) radiation: Experts believe that much of the worldwide increase in melanoma is related to an increase in the amount of time people spend in the sun. This disease is also more common in people who live in areas that get large amounts of UV radiation from the sun. In the United States, for example, melanoma is more common in Texas than in Minnesota, where the sun is not as strong. UV radiation from the sun causes premature aging of the skin and skin damage that can lead to melanoma. Artificial sources of UV radiation, such as sunlamps and tanning booths, also can cause skin damage and increase the risk of melanoma. Doctors encourage people to limit their exposure to natural UV radiation and to avoid artificial sources.

Doctors recommend that people take steps to help prevent and reduce the risk of melanoma caused by UV radiation:

Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever possible. When your shadow is shorter than you are, remember to protect yourself from the sun.

If you must be outside, wear long sleeves, long pants, and a hat with a wide brim.

Protect yourself from UV radiation that can penetrate light clothing, windshields, and windows.

Protect yourself from UV radiation reflected by sand, water, snow, and ice.

Help protect your skin by using a lotion, cream, or gel that contains sunscreen. Many doctors believe sunscreens may help prevent melanoma, especially sunscreens that reflect, absorb, and/or scatter both types of ultraviolet radiation. These sunscreen products will be labeled with “broad-spectrum coverage.” Sunscreens are rated in strength according to a sun protection factor (SPF). The higher the SPF, the more sunburn protection is provided. Sunscreens with an SPF value of 2 to 11 provide minimal protection against sunburns. Sunscreens with an SPF of 12 to 29 provide moderate protection. Those with an SPF of 30 or higher provide the most protection against sunburn.

Wear sunglasses that have UV-absorbing lenses. The label should specify that the lenses block at least 99 percent of UVA and UVB radiation. Sunglasses can protect both the eyes and the skin around the eyes.
 

People who are concerned about developing melanoma should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor’s advice will be based on the person’s personal and family history, medical history, and other risk factors.
Signs and Symptoms
Often, the first sign of melanoma is a change in the size, shape, color, or feel of an existing mole. Most melanomas have a black or blue-black area. Melanoma also may appear as a new mole. It may be black, abnormal, or “ugly looking.”

If you have a question or concern about something on your skin, see your doctor. Do not use the following pictures to try to diagnose it yourself. Pictures are useful examples, but they cannot take the place of a doctor’s examination.

Thinking of “ABCD” can help you remember what to watch for:

Asymmetry—The shape of one half does not match the other.

 

Border—The edges are often ragged, notched, blurred, or irregular in outline; the pigment may spread into the surrounding skin.

 

Color—The color is uneven. Shades of black, brown, and tan may be present. Areas of white, grey, red, pink, or blue also may be seen.

 

Diameter—There is a change in size, usually an increase. Melanomas are usually larger than the eraser of a pencil (1/4 inch or 5 millimeters).

 

Melanomas can vary greatly in how they look. Many show all of the ABCD features. However, some may show changes or abnormalities in only one or two of the ABCD features.

 

Melanomas in an early stage may be found when an existing mole changes slightly, for example, when a new black area forms. Newly formed fine scales and itching in a mole also are common symptoms of early melanoma. In more advanced melanoma, the texture of the mole may change. For example, it may become hard or lumpy. Melanomas may feel different from regular moles. More advanced tumors may itch, ooze, or bleed. But melanomas usually do not cause pain.

A skin examination is often part of a routine checkup by a health care provider. People also can check their own skin for new growths or other changes. (The “How To Do a Skin Self-Exam” section has a simple guide on how to do this skin self-exam.) Changes in the skin, such as a change in a mole, should be reported to the health care provider right away. The person may be referred to a dermatologist, a doctor who specializes in diseases of the skin.

Melanoma can be cured if it is diagnosed and treated when the tumor is thin and has not deeply invaded the skin. However, if a melanoma is not removed at its early stages, cancer cells may grow downward from the skin surface and invade healthy tissue. When a melanoma becomes thick and deep, the disease often spreads to other parts of the body and is difficult to control.

People who have had melanoma have a high risk of developing a new melanoma. People at risk for any reason should check their skin regularly and have regular skin exams by a health care provider.
Dysplastic Nevi
Some people have certain abnormal-looking moles (called dysplastic nevi or atypical moles) that are more likely than normal moles to develop into melanoma. Most people with dysplastic nevi have just a few of these abnormal moles; some people have many. People with dysplastic nevi and their health care provider should examine these moles regularly to watch for changes. (Additional information about moles and dysplastic nevi and melanoma risk is available in the NCI booklet What You Need To Know About™ Moles and Dysplastic Nevi.)

Dysplastic nevi often look very much like melanoma. Doctors with special training in skin diseases are in the best position to decide whether an abnormal-looking mole should be closely watched or removed and checked for cancer.

In some families, many members have a large number of dysplastic nevi, and some have had melanoma. Members of these families have a very high risk of melanoma. Doctors often recommend that they have frequent checkups (every 3 to 6 months) so that any problems can be detected early. The doctor may take pictures of a person’s skin to help show when changes occur.
Diagnosis
If the doctor suspects that a spot on the skin is melanoma, the patient will need to have a biopsy. A biopsy is the only way to make a definite diagnosis. In this procedure, the doctor tries to remove all of the suspicious-looking growth. This is an excisional biopsy. If the growth is too large to be removed entirely, the doctor removes a sample of the tissue. The doctor will never “shave off” or cauterize a growth that might be melanoma.

A biopsy can usually be done in the doctor’s office using local anesthesia. A pathologist then examines the tissue under a microscope to check for cancer cells. Sometimes it is helpful for more than one pathologist to check the tissue for cancer cells.

A person who needs a biopsy may want to ask the doctor the following questions:

Why do I need a biopsy?

How long will it take? Will it hurt?

Will the entire tumor be removed?

What side effects can I expect?

How soon will I know the results?

If I do have cancer, who will talk to me about treatment? When?
 
Staging
If the diagnosis is melanoma, the doctor needs to learn the extent, or stage, of the disease before planning treatment. Staging is a careful attempt to learn how thick the tumor is, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. The doctor may remove nearby lymph nodes to check for cancer cells. (Such surgery may be considered part of the treatment because removing cancerous lymph nodes may help control the disease.) The doctor also does a careful physical exam and, if the tumor is thick, may order chest x-rays, blood tests, and scans of the liver, bones, and brain.
Stages of Melanoma
The following stages are used for melanoma:

Stage 0: In stage 0, the melanoma cells are found only in the outer layer of skin cells and have not invaded deeper tissues.

Stage I: Melanoma in stage I is thin:

The tumor is no more than 1 millimeter (1/25 inch) thick. The outer layer (epidermis) of skin may appear scraped. (This is called an ulceration).

Or, the tumor is between 1 and 2 millimeters (1/12 inch) thick. There is no ulceration.

The melanoma cells have not spread to nearby lymph nodes.

Stage II: The tumor is at least 1 millimeter thick:

The tumor is between 1 and 2 millimeters thick. There is ulceration.

Or, the thickness of the tumor is more than 2 millimeters. There may be ulceration.

The melanoma cells have not spread to nearby lymph nodes.
Stage III: The melanoma cells have spread to nearby tissues:

The melanoma cells have spread to one or more nearby lymph nodes.

Or, the melanoma cells have spread to tissues just outside the original tumor but not to any lymph nodes.

Stage IV: The melanoma cells have spread to other organs, to lymph nodes, or to skin areas far away from the original tumor.

Recurrent: Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may have come back in the original site or in another part of the body.

Treatment
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient’s needs. Treatment for melanoma depends on the extent of the disease, the patient’s age and general health, and other factors.

People with melanoma are often treated by a team of specialists. The team may include a dermatologist, surgeon, medical oncologist, radiation oncologist, and plastic surgeon.
Getting a Second Opinion
Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor for a second opinion:

The patient’s doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.

The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.

A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors’ names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on “Who’s Certified.”)

 
Preparing for Treatment
People with melanoma often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a melanoma can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.

These are some questions a person may want to ask the doctor before treatment begins:

What is my diagnosis?

What is the stage of my disease?

What are my treatment choices? Which do you recommend for me? Why?

What are the benefits of each kind of treatment?

What are the risks and possible side effects of each treatment?

How will I feel after surgery?

If I have pain, how will it be controlled?

Will I need more treatment after surgery?

Will there be a scar? Will I need a skin graft or plastic surgery?

What is the treatment likely to cost?

Will treatment affect my normal activities? If so, for how long?

How often will I need checkups?

Would a clinical trial (research study) be appropriate for me? Can you help me find one?
 

People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Methods of Treatment
People with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.

At any stage of disease, people with melanoma may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called symptom management, supportive care, or palliative care.

The doctor is the best person to describe the treatment choices and discuss the expected results.

A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on “The Promise of Cancer Research” has more information about clinical trials.
Surgery
Surgery is the usual treatment for melanoma. The surgeon removes the tumor and some normal tissue around it. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin:

The doctor may be able to completely remove a very thin melanoma during the biopsy. Further surgery may not be necessary.

If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas. If the melanoma is thick, the doctor may need to remove a larger margin of tissue.

If a large area of tissue is removed, the surgeon may do a skin graft. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.

Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has also spread to other parts of the body. Two procedures are used to remove the lymph nodes:

Sentinel lymph node biopsy—The sentinel lymph node biopsy is done after the biopsy of the melanoma but before the wider excision of the tumor. A radioactive substance is injected near the melanoma. The surgeon follows the movement of the substance on a computer screen. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping.) The surgeon removes the sentinel node(s) to check for cancer cells.

If a sentinel node contains cancer cells, the surgeon removes the rest of the lymph nodes in the area. However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.

Lymph node dissection—The surgeon removes all the lymph nodes in the area of the melanoma.

Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. The patient may receive biological therapy.

Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods.

 
Chemotherapy
Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat melanoma. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor’s office, or at home). However, depending on which drugs are given and the patient’s general health, a short hospital stay may be needed.

People with melanoma may receive chemotherapy in one of the following ways:

By mouth or injection—Either way, the drugs enter the bloodstream and travel throughout the body.

Isolated limb perfusion (also called isolated arterial perfusion)—For melanoma on an arm or leg, chemotherapy drugs are put directly into the bloodstream of that limb. The flow of blood to and from the limb is stopped for a while. This allows most of the drug to reach the tumor directly. Most of the chemotherapy remains in that limb.

The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.
Biological Therapy
Biological therapy (also called immunotherapy) is a form of treatment that uses the body’s immune system, either directly or indirectly, to fight cancer or to reduce side effects caused by some cancer treatments. Biological therapy for melanoma uses substances called cytokines. The body normally produces cytokines in small amounts in response to infections and other diseases. Using modern laboratory techniques, scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.
Radiation Therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. The patient usually has treatment at a hospital or clinic, five days a week for several weeks. Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.
Treatment Choices by Stage
The following are brief descriptions of the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

Stage 0

People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.

Stage I

People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.

Stage II or Stage III

People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.

Stage IV

People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better—physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.

The patient may have one of the following:

Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body

Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

People with advanced melanoma can find helpful information in the National Cancer Institute booklet Pain Control: A Guide for People with Cancer and Their Families.
Recurrent Melanoma
Treatment for recurrent melanoma depends on where the cancer came back, which treatments the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.

The patient may have one of the following:

Surgery to remove the tumor

Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

Heated chemotherapy drugs injected directly into the tumor

 
Side Effects of Treatment
Because treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections “National Cancer Institute Information Resources” and “National Cancer Institute Booklets” for other sources of information about side effects.
Surgery
The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.

Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can (while still protecting against recurrence). In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, the doctor must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large growths, these scars will still be quite noticeable.

Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, insect bites, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.
Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:

Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.

Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.

Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.
Biological Therapy
The side effects of biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also get a skin rash. These problems can be severe, but they go away after treatment stops.
Radiation Therapy
The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur in the treated area include red or dry skin and hair loss. Radiation therapy also may cause fatigue. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.
Nutrition
People with melanoma may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. Nevertheless, patients should try to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.

The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful ideas and recipes. The “National Cancer Institute Booklets” section tells how to get this publication.

Followup Care
Melanoma patients have a high risk of developing new melanomas. Some also are at risk of a recurrence of the original melanoma in nearby skin or in other parts of the body.

To increase the chance of detecting a new or recurrent melanoma as early as possible, patients should follow their doctor’s schedule for regular checkups. It is especially important for patients who have dysplastic nevi and a family history of melanoma to have frequent checkups. Patients also should examine their skin monthly (keeping in mind the “ABCD” guidelines in the “Signs and Symptoms” section, and the skin self-exam described in “How To Do a Skin Self-Exam”). They should follow their doctor’s advice about how to reduce their chance of developing another melanoma. General information about reducing the risk of melanoma is described in the “Melanoma: Who’s at Risk?” section.

The chance of recurrence is greater for patients whose melanoma was thick or had spread to nearby tissue than for patients with very thin melanomas. Followup care for those who have a high risk of recurrence may include x-rays, blood tests, and scans of the chest, liver, bones, and brain.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about followup care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for getting the most out of medical visits. It describes the kinds of help people may need.

A person who has been treated for melanoma may want to ask the doctor the following questions:

How often should I have checkups?

What special precautions should I take to avoid sun exposure?

Are my family members at risk of melanoma? Should they schedule an appointment with their doctor for an examination?
 
Support for People with Melanoma
Living with a serious disease such as melanoma is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet.

People living with melanoma may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills also are common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

The Cancer Information Service at 1-800-4-CANCER can send publications and provide information to help patients and their families locate programs and services.

The Promise of Cancer Research
Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new ways to treat melanomas. Research already has led to advances, and researchers continue to search for more effective approaches.

Patients who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.

Researchers are testing new anticancer drugs. They are looking at combining chemotherapy with radiation therapy. Other studies are combining chemotherapy with biological therapy. Scientists also are studying several cancer vaccines and a type of gene therapy designed to help the immune system kill cancer cells.

How To Do a Skin Self-Exam
Your doctor or nurse may recommend that you do a regular skin self-exam. If your doctor has taken photos of your skin, comparing your skin to the photos can help you check for changes.

The best time to do a skin self-exam is after a shower or bath. You should check your skin in a well-lighted room using a full-length mirror and a hand-held mirror. It’s best to begin by learning where your birthmarks, moles, and blemishes are and what they usually look and feel like.

Check for anything new:

A new mole (that looks abnormal)

A change in the size, shape, color, or texture of a mole

A sore that does not heal

Check yourself from head to toe. Don’t forget to check all areas of the skin, including the back, the scalp, between the buttocks, and the genital area.

Look at your face, neck, ears, and scalp. You may want to use a comb or a blow dryer to move your hair so that you can see better. You also may want to have a relative or friend check through your hair because this is difficult to do yourself.

Look at the front and back of your body in the mirror, then raise your arms and look at your left and right sides.

Bend your elbows and look carefully at your fingernails, palms, forearms (including the undersides), and upper arms.

Examine the back, front, and sides of your legs. Also look between your buttocks and around your genital area.

Sit and closely examine your feet, including the toenails, the soles, and the spaces between the toes.

By checking your skin regularly, you will become familiar with what is normal for you. It may be helpful to record the dates of your skin exams and to write notes about the way your skin looks. If you find anything unusual, see your doctor right away.

 

 
Source: National Cancer Institute(www.cancer.gov), National Institutes of Health

If you have any specific question, you can ask the doctors at - www.MyMedExpert.com

MyMedExpert - Medical Consultation Online

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What can you do to decrease your risk for developing cancer of the colon or rectum?

While everyone can benefit from regular screening, if you have a family history of colorectal cancer or another bowel disorder, you should be even more diligent. Ask your doctor how often you should be screened and which colorectal tests you should undergo. In the meantime, there are other things you can do.

DIET: Diet plays a large role in colorectal cancers. Migrants to the United States from Japan and other countries where rates of colorectal cancer are lower than in the U.S. have higher rates of colorectal cancers than do those who remain in their native country. Children of these migrants develop colorectal cancers at rates equal to or even higher than those of the United States white population. Studies have shown that people who eat a lot of well-done, fried, or barbequed meats have an increased risk of developing colorectal cancer. For prevention, NCI encourages people to eat five or more servings of vegetables and fruits each day as part of a low-fat, high-fiber diet and to follow the Dietary Guidelines for Americans.

EXERCISE: Two words: Get moving. Exercise may lower a person’s risk for colorectal cancer, NIDDK experts contend, because it speeds the amount of time it takes for wastes to leave your body.

SMOKING: Do all you can to quit. In addition to smoking’s well-established link to cancers of the lung and head and neck, long-term smoking that begins before age 30 also increases the risk of developing colorectal cancer as well as precancerous polyps.

ALCOHOL: Excessive alcohol consumption — drinking two or more alcoholic drinks a night — has been associated with an increased prevalence of rectal cancer.

If you have any specific question, you can ask the doctors at www.mymedexpert.com

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A lower gastrointestinal (GI) series uses x rays to diagnose problems in the large intestine, which includes the colon and rectum. The lower GI series may show problems like abnormal growths, ulcers, polyps, diverticuli, and colon cancer.

Before taking x rays of your colon and rectum, the radiologist will put a thick liquid called barium into your colon. This is why a lower GI series is sometimes called a barium enema. The barium coats the lining of the colon and rectum and makes these organs, and any signs of disease in them, show up more clearly on x rays. It also helps the radiologist see the size and shape of the colon and rectum.

You may be uncomfortable during the lower GI series. The barium will cause fullness and pressure in your abdomen and will make you feel the urge to have a bowel movement. However, that rarely happens because the tube used to inject the barium has a balloon on the end of it that prevents the liquid from coming back out.

You may be asked to change positions while x rays are taken. Different positions give different views of the colon. After the radiologist is finished taking x rays, you will be able to go to the bathroom. The radiologist may also take an x ray of the empty colon afterwards.

A lower GI series takes about 1 to 2 hours. The barium may cause constipation and make your stool turn gray or white for a few days after the procedure.

If you have any specific question, you can ask the doctors at www.mymedexpert.com

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What is a colonoscopy?

A colonoscopy (koh-luh-NAH-skuh-pee) allows a doctor to look inside the entire large intestine. The procedure enables the physician to see things such as inflamed tissue, abnormal growths, and ulcers. It is most often used to look for early signs of cancer in the colon and rectum. It is also used to look for causes of unexplained changes in bowel habits and to evaluate symptoms like abdominal pain, rectal bleeding, and weight loss.

Procedure

For the colonoscopy, you will lie on your left side on the examining table. You will be given pain medication and a moderate sedative to keep you comfortable and help you relax during the exam. The doctor and a nurse will monitor your vital signs, look for any signs of discomfort, and make adjustments as needed.

The doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope (koh-LON-oh-skope). The scope transmits an image of the inside of the colon onto a video screen so the doctor can carefully examine the lining of the colon. The scope bends so the doctor can move it around the curves of your colon.

You may be asked to change positions at times so the doctor can more easily move the scope to better see the different parts of your colon. The scope blows air into your colon and inflates it, which helps give the doctor a better view. Most patients do not remember the procedure afterwards.

The doctor can remove most abnormal growths in your colon, like a polyp, which is a growth in the lining of the bowel. Polyps are removed using tiny tools passed through the scope. Most polyps are not cancerous, but they could turn into cancer. Just looking at a polyp is not enough to tell if it is cancerous. The polyps are sent to a lab for testing. By identifying and removing polyps, a colonoscopy likely prevents most cancers from forming.

The doctor can also remove tissue samples to test in the lab for diseases of the colon (biopsy). In addition, if any bleeding occurs in the colon, the doctor can pass a laser, heater probe, electrical probe, or special medicines through the scope to stop the bleeding. The tissue removal and treatments to stop bleeding usually do not cause pain. In many cases, a colonoscopy allows for accurate diagnosis and treatment of colon abnormalities without the need for a major operation.

During the procedure you may feel mild cramping. You can reduce the cramping by taking several slow, deep breaths. When the doctor has finished, the colonoscope is slowly withdrawn while the lining of your bowel is carefully examined. Bleeding and puncture of the colon are possible but uncommon complications of a colonoscopy.

A colonoscopy usually takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You may feel some cramping or the sensation of having gas after the procedure is completed, but it usually stops within an hour. You will need to remain at the colonoscopy facility for 1 to 2 hours so the sedative can wear off.

Rarely, some people experience severe abdominal pain, fever, bloody bowel movements, dizziness, or weakness afterward. If you have any of these side effects, contact your physician immediately. Read your discharge instructions carefully. Medications such as blood-thinners may need to be stopped for a short time after having your colonoscopy, especially if a biopsy was performed or polyps were removed. Full recovery by the next day is normal and expected and you may return to your regular activities.

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# What are the advantages of cryosurgery?

Cryosurgery offers advantages over other methods of cancer treatment. It is less invasive than surgery, involving only a small incision or insertion of the cryoprobe through the skin. Consequently, pain, bleeding, and other complications of surgery are minimized. Cryosurgery is less expensive than other treatments and requires shorter recovery time and a shorter hospital stay, or no hospital stay at all. Sometimes cryosurgery can be done using only local anesthesia.

Because physicians can focus cryosurgical treatment on a limited area, they can avoid the destruction of nearby healthy tissue. The treatment can be safely repeated and may be used along with standard treatments such as surgery, chemotherapy, hormone therapy, and radiation. Cryosurgery may offer an option for treating cancers that are considered inoperable or that do not respond to standard treatments. Furthermore, it can be used for patients who are not good candidates for conventional surgery because of their age or other medical conditions.

# What are the disadvantages of cryosurgery?

The major disadvantage of cryosurgery is the uncertainty surrounding its long-term effectiveness. While cryosurgery may be effective in treating tumors the physician can see by using imaging tests (tests that produce pictures of areas inside the body), it can miss microscopic cancer spread. Furthermore, because the effectiveness of the technique is still being assessed, insurance coverage issues may arise.

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Cryosurgery does have side effects, although they may be less severe than those associated with surgery or radiation therapy. The effects depend on the location of the tumor. Cryosurgery for cervical intraepithelial neoplasia has not been shown to affect a woman’s fertility, but it can cause cramping, pain, or bleeding. When used to treat skin cancer (including Kaposi’s sarcoma), cryosurgery may cause scarring and swelling; if nerves are damaged, loss of sensation may occur, and, rarely, it may cause a loss of pigmentation and loss of hair in the treated area. When used to treat tumors of the bone, cryosurgery may lead to the destruction of nearby bone tissue and result in fractures, but these effects may not be seen for some time after the initial treatment and can often be delayed with other treatments. In rare cases, cryosurgery may interact badly with certain types of chemotherapy. Although the side effects of surgery may be less severe than those associated with conventional surgery or radiation, more studies are needed to determine the long-term effects.

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Cryosurgery can be used to treat men who have early-stage prostate cancer that is confined to the prostate gland. It is less well established than standard prostatectomy and various types of radiation therapy. Long-term outcomes are not known. Because it is effective only in small areas, cryosurgery is not used to treat prostate cancer that has spread outside the gland, or to distant parts of the body.

Some advantages of cryosurgery are that the procedure can be repeated, and it can be used to treat men who cannot have surgery or radiation therapy because of their age or other medical problems.

Cryosurgery for the prostate gland can cause side effects. These side effects may occur more often in men who have had radiation to the prostate.

* Cryosurgery may obstruct urine flow or cause incontinence (lack of control over urine flow); often, these side effects are temporary.
* Many men become impotent (loss of sexual function).
* In some cases, the surgery has caused injury to the rectum.

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# How do oral contraceptives affect breast cancer risk?

A woman’s risk of developing breast cancer depends on several factors, some of which are related to her natural hormones. Hormonal factors that increase the risk of breast cancer include conditions that may allow high levels of hormones to persist for long periods of time, such as beginning menstruation at an early age (before age 12), experiencing menopause at a late age (after age 55), having a first child after age 30, and not having children at all.

A 1996 analysis of worldwide epidemiologic data conducted by the Collaborative Group on Hormonal Factors in Breast Cancer found that women who were current or recent users of birth control pills had a slightly elevated risk of developing breast cancer. The risk was highest for women who started using OCs as teenagers. However, 10 or more years after women stopped using OCs, their risk of developing breast cancer returned to the same level as if they had never used birth control pills, regardless of family history of breast cancer, reproductive history, geographic area of residence, ethnic background, differences in study design, dose and type of hormone, or duration of use. In addition, breast cancers diagnosed in women after 10 or more years of not using OCs were less advanced than breast cancers diagnosed in women who had never used OCs. To conduct this analysis, the researchers examined the results of 54 studies. The analysis involved 53,297 women with breast cancer and 100,239 women without breast cancer. More than 200 researchers participated in this combined analysis of their original studies, which represented about 90 percent of the epidemiological studies throughout the world that had investigated the possible relationship between OCs and breast cancer (2).

The findings of the Women’s Contraceptive and Reproductive Experiences (Women’s CARE) study were in contrast to those described above. The Women’s CARE study examined the use of OCs as a risk factor for breast cancer in women ages 35 to 64. Researchers interviewed 4,575 women who were diagnosed with breast cancer between 1994 and 1998, and 4,682 women who did not have breast cancer. Investigators collected detailed information about the participants’ use of OCs, reproductive history, health, and family history. The results, which were published in 2002, indicated that current or former use of OCs did not significantly increase the risk of breast cancer. The findings were similar for white and black women. Factors such as longer periods of use, higher doses of estrogen, initiation of OC use before age 20, and OC use by women with a family history of breast cancer were not associated with an increased risk of the disease (3).

In a National Cancer Institute (NCI)-sponsored study published in 2003, researchers examined risk factors for breast cancer among women ages 20 to 34 compared with women ages 35 to 54. Women diagnosed with breast cancer were asked whether they had used OCs for more than 6 months before diagnosis and, if so, whether the most recent use had been within 5 years, 5 to 10 years, or more than 10 years. The results indicated that the risk was highest for women who used OCs within 5 years prior to diagnosis, particularly in the younger group.

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#  How does a doctor know whether a cancer is a primary or a metastatic tumor?

To determine whether a tumor is primary or metastatic, a pathologist examines a sample of the tumor under a microscope. In general, cancer cells look like abnormal versions of cells in the tissue where the cancer began. Using specialized diagnostic tests, a pathologist is often able to tell where the cancer cells came from. Markers or antigens found in or on the cancer cells can indicate the primary site of the cancer.

Metastatic cancers may be found before or at the same time as the primary tumor, or months or years later. When a new tumor is found in a patient who has been treated for cancer in the past, it is more often a metastasis than another primary tumor.

# Is it possible to have a metastatic tumor without having a primary cancer?

No. A metastatic tumor always starts from cancer cells in another part of the body. In most cases, when a metastatic tumor is found first, the primary tumor can be found. The search for the primary tumor may involve lab tests, x-rays, and other procedures. However, in a small number of cases, a metastatic tumor is diagnosed but the primary tumor cannot be found, in spite of extensive tests. The pathologist knows the tumor is metastatic because the cells are not like those in the organ or tissue in which the tumor is found. Doctors refer to the primary tumor as unknown or occult (hidden), and the patient is said to have cancer of unknown primary origin (CUP). Because diagnostic techniques are constantly improving, the number of cases of CUP is going down. More information about CUP can be found in the National Cancer Institute (NCI) fact sheet Cancer of Unknown Primary Origin, which is available at http://www.cancer.gov/cancertopics/factsheet/Sites-Types/unknownprimary on the Internet.

# What treatments are used for metastatic cancer?

When cancer has metastasized, it may be treated with chemotherapy, radiation therapy, biological therapy, hormone therapy, surgery, cryosurgery, or a combination of these. The choice of treatment generally depends on the type of primary cancer, the size and location of the metastasis, the patient’s age and general health, and the types of treatments the patient has had in the past. In patients with CUP, it is possible to treat the disease even though the primary tumor has not been located. The goal of treatment may be to control the cancer, or to relieve symptoms or side effects of treatment.

# Are new treatments for metastatic cancer being developed?

Yes, many new cancer treatments are under study. To develop new treatments, the NCI sponsors clinical trials (research studies) with cancer patients in many hospitals, universities, medical schools, and cancer centers around the country. Clinical trials are a critical step in the improvement of treatment. Before any new treatment can be recommended for general use, doctors conduct studies to find out whether the treatment is both safe for patients and effective against the disease. The results of such studies have led to progress not only in the treatment of cancer, but in the detection, diagnosis, and prevention of the disease as well. Patients interested in taking part in a clinical trial should talk with their doctor.

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