Thursday, June 23, 2016

Living with cancer blog

Making the tough choice on cancer treatment

By Lonnie Fynskov, R.N. June 18, 2016
By the time you read this, you've probably made dozens of decisions for the day. Some, such as deciding whether to hit the snooze button one more time, really don't make much of a difference in the big scheme of things. Decisions related to cancer treatment options, however, weigh much heavier in our mind.
With the focus on evidence-based medicine, we look to research to help us understand how effective the various treatment options may be, what are their expected side effects, how frequently do those side effects occur, etc.
Sometimes the options are equally effective, but present the possibility of very different side effects and future treatment needs. That was the situation for someone I spoke with last week who had just learned her breast biopsy report was positive for ductal carcinoma in situ.
Her choice was one of two surgeries that would give her the same clinical outcome, according to the evidence. This decision determined the follow-up radiation plan and hormone regime. She was told "the choice is yours to make." Wow or ugh?
Both breast cancer and prostate cancer patients may be presented with treatment options and told they can decide how to proceed.
Healthcare providers know people handle situations in their own unique way. Some prefer a less invasive surgery with more long-term medical management, while others choose a more involved surgery with less post-operative follow-up treatment.
Because we're all different, it seems like it would be wonderful to have more than one treatment option. But we're also all different in our comfort level with making that choice.
Some people take the information, confidently make a decision and don't look back. Others prefer to have the experts weigh in on what they feel is best because they have the experience and wealth of knowledge already in hand.
A new diagnosis of cancer is incredibly stressful, and this stress can make it even more difficult to make decisions. As the significance of the decision increases, so does the anxiety that the wrong option may be chosen.
If you were given more than one treatment option, how did you make your decision and how did you deal with the emotions that accompanied that process? Please share your decision method so we can learn from each other in these situations.

Monday, June 20, 2016


Your Cancer Care Team

Medical oncologist Anas Younes leads a multidisciplinary team of experts

Translate this page

At Memorial Sloan Kettering, patient care is a team effort. Each of our patient care teams combines the skills and experience of several healthcare professionals, many of whom specialize in diagnosing and treating one type of cancer. Our team members meet regularly to discuss patients’ diagnostic and treatment information, meaning that each patient benefits from a wide range of expertise. Having representatives of many different disciplines involved in your care ensures that you will receive the best possible treatment for your specific needs.
During your treatment at Memorial Sloan Kettering, you may encounter a variety of healthcare professionals. Here is information about their roles on the patient care team.

Treatment Team

For most cancers, treatment is led by one or more primary physicians, including a medical oncologist, a surgical oncologist, and a radiation oncologist. For some cancers, you may also see an interventional radiologist. Each of these physicians brings a defined set of expertise and techniques for treating cancer.
At Memorial Sloan Kettering, members of each treatment team specialize in treating one type of cancer. This means that the physicians and other healthcare professionals on your treatment team are highly experienced in caring for patients with the type of cancer you have. Working together, your treatment team will develop a plan for the combination of treatments that will lead to the best possible outcome for you.
To locate doctors who specialize in treating a specific type of cancer, or to schedule an appointment, please visitFind a Doctor.

Medical Oncologist

Surgical Oncologist

Radiation Oncologist

Interventional Radiologist


Nurses play an important role in caring for patients at Memorial Sloan Kettering, and are often the members of the treatment team with whom you will have the most contact. Nurses bring extraordinary knowledge, experience, and expertise to your care, because they specialize in helping people with your particular type of cancer. Nurses will help you through your experience at Memorial Sloan Kettering, whether you are being treated in the hospital or as an outpatient.
At Memorial Sloan Kettering, nurses collaborate with doctors and other members of your patient care team to develop a treatment plan that is right for you. The nurses on your team provide a range of services — administering therapies, monitoring your treatment and watching out for side effects, educating you and your family about what to expect during treatment, and offering emotional support. Nurses also help coordinate your appointments, communicate important information to various members of your patient care team, and keep track of other details related to your treatment. Nurses at Memorial Sloan Kettering maintain a patient-centered focus, placing your needs and preferences first.
Here is information about some of the nursing professionals you may encounter at Memorial Sloan Kettering:

Clinical Nurse

Nurse Practitioner

Clinical Nurse Specialist

Nursing Assistant and Patient Care Technician

Diagnostic Team

The diagnostic team at Memorial Sloan Kettering includes doctors and other healthcare professionals who use information from blood tests, imaging tests, and other specialized diagnostic tests to identify the type and location of cancer and determine the stage (extent) of the disease. Like the treatment team, members of the diagnostic team are trained to identify specific types of cancer. The diagnostic team works with the treatment team to develop an individualized treatment plan for each patient.



Nuclear Medicine Specialist

Genetic Cancer Specialist

Specialized Care

Memorial-Sloan Kettering’s multidisciplinary patient care teams include a variety of medical specialists and subspecialists. Our specialists perform several diagnostic and therapeutic tasks that enhance the overall coordination and quality of care.




Hematologist and Hematologic Oncologist

Medical Physicist

Neurologist, Neuro-Oncologist, and Neurosurgeon


Radiation Therapist


Physician Assistant

Supportive Care

Memorial Sloan Kettering’s patient care teams include healthcare professionals from a variety of disciplines who focus on helping patients and their families cope with a cancer diagnosis. They provide services that address the many physical and emotional issues that can arise during cancer therapy, and help patients adjust to life after treatment.

Genetic Counselor


Oncology Social Worker


Rehabilitation Therapist

CreditDominic Kesterton
Last year, I wrote a column arguing that evidence shows that diet, not exercise, is the key to weight loss. Since then, I have been troubled at how some readers have taken this to mean that exercise therefore has no value.
Nothing could be further from the truth. Of all the things we as physicians can recommend for health, few provide as much benefit as physical activity.
In 2015, the Academy of Medical Royal Colleges put out a report calling exercise a “miracle cure.” This isn’t one of those things with just some cohort or case-control studies behind it, either. There are many, many randomized controlled trials. A huge meta-analysis examined the effect of exercise therapy on outcomes in people with chronic diseases.
Let’s start with musculoskeletal diseases. Researchers found 32 trials looking specifically at the effect of exercise on pain and function of patients with osteoarthritis of the knee alone. That’s incredibly specific, and it’s impressive so much research has focused on this one topic. Exercise improved those outcomes. Ten more studies showed, over all, that exercise therapy increases aerobic capacity and muscle strength in patients with rheumatoid arthritis. Other studies proved its benefits in other musculoskeletal conditions, like ankylosing spondylitis, and even some types of back pain.
For people (mostly middle-aged men) who had had a heart attack, exercise therapy reduced all causes of mortality by 27 percent and cardiac mortality by 31 percent. Fourteen additional controlled trials showed physiological benefits in those with heart failure. Exercise also has been shown to lower blood pressure in patients with hypertension, and improve cholesterol and triglyceride levels.
People with diabetes who exercise have lower Hba1c values, which is the marker of blood sugar control, low enough to probably reduce the risk of complications from the disease. Twenty randomized controlled trials have showed that patients with chronic obstructive pulmonary disease can walk farther and function better if they exercise.
Multiple studies have found that exercise improves physical function and health-related quality of life in people who have Parkinson’s disease. Six more studies showed that exercise improves muscle power and mobility-related activities in people with multiple sclerosis. It even appeared to improve those patients’ moods.
The overall results of 23 randomized controlled trials showed that exercise most likely improves the symptoms of depression. Five others appear to show that it improves symptoms in patients with chronic fatigue syndrome. In trials, exercise even lessened fatigue in patients who are undergoing therapy for cancer.
What other intervention can claim results like these?
Even studies of older, hospitalized patients show a beneficial effect from multidisciplinary interventions that include exercise. Those randomized to such interventions in the hospital were more likely to be discharged to go home, and to spend less time in the hospital over all — and at a lower cost.
While we don’t think of it this way, you can make a pretty good argument that exercise is as good as drugs for many conditions. A 2013 meta-analysis of meta-analyses (that’s how much data we have) combined and analyzed the results from 16 reviews of randomized controlled trials of drug and exercise interventions in reducing mortality. Collectively, these included 305 trials with almost 340,000 participants.
Diuretic drugs (but not all drugs) were shown to be superior to exercise in preventing death from heart failure. But exercise was found to be equally good as drugs in preventing mortality from coronary heart disease. Exercise was better than drugs in preventing death among patients from strokes.
Many people will be surprised at how little you need to do to achieve these results. Years ago, in an effort to get in shape, I tried the P90X routine. It proved too hard for me. Later, when I tried Insanity, it beat me so badly that people at work kept asking me if I was ill. Two years ago, I triedP90X3. It was a bit more manageable, but I still couldn’t keep it up.
I’m not alone in thinking that physical activity to improve health should be hard. When I hear friends talk about exercising, they discuss running marathons, participating in cross-fit classes or sacrificing themselves on the altar of Soul Cycle. That misses the point, unfortunately. All of these are way, way more than you need to do to get the benefits I’ve already described.
The recommendations for exercise are 150 minutes per week of moderate intensity physical activity for adults, or about 30 minutes each weekday.
Moderate intensity is probably much less than you think. Walking briskly, at 3 to 4 miles per hour or so, qualifies. So does bicycling slower than 10 miles an hour. Anything that gets your heart rate somewhere between 110 and 140 beats per minute is enough. Even vacuuming, mowing the lawn or actively walking your dog might qualify.
Today, my goals are much more modest. Trekking from my office to the clinic and back again gives me 30 minutes of exercise. Or, I walk to the supermarket from my office to grab lunch, at a mile each way. In colder weather, I spend half an hour on the elliptical machine. Doing this five days a week gets me the activity I need.
While it feels as if there’s nothing we can do to change people’s behavior, evidence exists to the contrary. A systematic review and meta-analysis of advice and counseling by health professionals found that promotion of physical activity works. Doctors and clinics that made efforts to promote exercise to patients needed to engage 12 adults on the subject in order to get one additional adult to meet recommended levels of activity one year later. That might not sound impressive, but it’s one of the best measures of “number needed to treat” that I’ve presented here at The Upshot.
After the Academy of Medical Royal Colleges wrote its report, an editorial in the BMJ, a prominent medical journal, countered that exercise wasn’t a “miracle cure.” Instead, the authors argued it was “the best buy for public health.”
If that’s the best “counterpoint,” then physical activity seems like a no-brainer.