Advanced Cancer Overview

Transcription

1 Advanced Cancer Overview The information that follows is an overview of this type of cancer. It is based on the more detailed information in our document, Advanced Cancer. This document and other information can be obtained by calling or visiting our Web site at It may be hard to think and talk about cancer that has spread or is no longer responding to treatment. Everyone with cancer hopes that their cancer will be cured, but this is not always possible. You may still get cancer treatment, but the goal may no longer be to cure the cancer. At this time the goal is often to control the cancer and any symptoms it causes so you can enjoy life and feel as good as you can for as long as you can. Doctors call a cancer advanced based on things like: How much cancer is present How far the cancer has spread How much the cancer has affected the way your body works Whether there is any treatment that works for your cancer Here we will try to help you better understand what advanced cancer is, what you can expect if it happens, and what can be done for it. Talk to your cancer care team about any questions or concerns you may have. You, your loved ones, and your medical team still have vital choices to make, and it s important to keep in mind that you are still in control of what happens during this time. What is advanced cancer? Not all doctors use the term advanced cancer to mean the exact same thing. When we refer to advanced cancer here, we are talking about cancers that cannot be cured. Advanced cancers have usually spread from where they started to other parts of the body. This is known as metastatic cancer. But not all advanced cancers are metastatic. A cancer can also be called advanced if it involves a vital organ and can't be removed. For more on metastatic cancer, see the section called What is metastatic cancer? On the other hand, not all metastatic cancers are advanced cancers. Some cancers, such as testicular cancer, may spread to other parts of the body but still can be cured.

2 You might also hear the term locally advanced cancer. This is usually used to describe cancer that has grown outside of the organ where it started and into nearby tissues. But it has not yet spread to distant parts of the body. Some of these cancers may be "advanced" as we are using the term here. For instance, locally advanced pancreatic cancer is often not curable. But other locally advanced cancers, like some prostate cancers, may be cured. If you or a loved one are told that you have advanced cancer, it is very important to find out just what the doctor means. Some may use the term to describe metastatic cancer, while others might mean something different. Be sure you understand what the doctor is saying. Advanced cancer can often be treated. Even if there is no cure, treatment can sometimes shrink the cancer, help relieve symptoms, and help you live longer. Some people can live many years with advanced cancer. Every person's cancer is unique. Your cancer may respond in a different way to treatments and grow at a different rate from the same type of cancer in someone else. For some people the cancer may already be advanced when they first find out they have the disease. Other people may develop advanced cancer years after treatment. Advanced cancer can cause symptoms that get worse and need treatment to help control them. These symptoms can almost always be treated. What is recurrent cancer? When cancer comes back in a person who seemed to be cancer-free after treatment, it is called recurrent cancer. Cancer can come back: In or near the same place it started or very close by -- this is called local recurrence In lymph nodes near the place where it started -- this is called regional recurrence In distant parts of the body -- this is called distant recurrence or metastatic recurrence Recurrent cancer is often harder to treat than the first cancer, but it is not always advanced cancer. For instance, a small cancer that was first treated with surgery and comes back in the same area (locally) can sometimes be treated or even cured with more surgery. Cancers that come back farther away from the original cancer site are more likely to be advanced cancers. What is metastatic cancer? Metastatic cancer is cancer that has spread from the part of the body where it started (its primary site) to other parts of the body. Keep in mind that when cancer spreads in this way it is still named after the part of the body where it started.

3 The Lymph System If the cells travel through lymph system, they may end up in the lymph nodes (small, bean-sized collections of immune cells) or spread to other organs. If the cells travel through the bloodstream they can go to any part of the body. Most often, the cancer cells break off and travel in the bloodstream. Many of these cells die, but some may settle in a new area, begin to grow, and form new tumors. This spread of cancer to a new part of the body is called metastasis. Cancer cells go through certain changes as they spread to new parts of the body. They have to be able to break away from the first tumor and get into the bloodstream or lymph system. At some point they need to attach to the wall of the blood or lymph vessel and move through the wall into a new organ. Then they need to be able to grow and thrive in this new place. All the while, they need to be able to avoid attacks from the body's immune system. Going through all these steps means the cells that start new tumors may no longer be just the same as the ones in the tumor they started in. This may make them harder to treat. But even when cancer has spread to a new place, it is still named after the part of the body where it started. For instance, if prostate cancer spreads to the bones, it is still called prostate cancer (not

4 bone cancer). The doctor will offer treatments that have been shown to help against metastatic prostate cancer. Likewise, breast cancer that has spread to the lungs it is still called breast cancer, not lung cancer, and is treated as metastatic breast cancer. Sometimes the new tumors have already begun to grow when the cancer is first found. In some cases the metastasis may be found before the primary tumor is found. If cancer is widely spread throughout the body when it is found, it may be hard to figure out where it started. This is called cancer of unknown primary. It is covered in our document Cancer of Unknown Primary. Why cancer cells spread to certain parts of the body Cancer spreads when cancer cells break off and get into nearby blood or lymph vessels. Most cancer cells that have broken away from the place where they started are carried in these vessels until they end up in the next "downstream" organ or set of lymph nodes. This explains why breast cancer often spreads to the underarm lymph nodes but rarely to lymph nodes in the groin. Many cancers spread to the lungs because the heart pumps blood from the rest of the body through the lung's blood vessels before sending it elsewhere. Sometimes the pattern of spread is not explained by where things are in the body. Some cancer cells seem to "home in" on certain places, perhaps because of substances on their surfaces that stick to cells in these organs. In other cases, the organ itself may release substances that cause the cancer cells to grow faster. Which cancers spread where This is a brief list of where different types of cancer are likely to spread. It is not a list of every place where a cancer could spread. To learn more about a given cancer, please see our document for that cancer site.

5 Bladder: Bladder cancer tends to stay in the same area and grow into nearby tissues, like the pelvic wall. It can also spread to the lungs, liver, and bone. Brain: Brain tumors rarely spread outside the brain. They mainly grow within the brain and sometimes into the spinal cord. Breast: Breast cancer most often spreads to the bones, but it can also spread to the liver, lung, and brain. As the cancer grows, it may affect any organ. It can also spread to the skin near where it started. Colon and rectum: The most common place for colon or rectal cancer to spread is the liver or the lungs. It may also spread to nearly any other organ. Rectal cancer can spread within the pelvis, where the rectal cancer started. This can be painful because it often grows into nerves and bones in this area. Esophagus: Esophageal cancer mostly grows near where it started. It can grow into nearby organs or major blood vessels, which can make it hard to treat. Kidney: Kidney (renal) cancer can grow into nearby tissues. It most often spreads to the lungs and bones. Leukemia: Because it is already in the blood, leukemia may be thought to have spread throughout body when it is found. It can grow and fill the bone marrow with leukemia cells. The normal bone marrow is replaced and cannot make new blood cells. Some leukemias may spread outside of the blood and into the fluid that surrounds the brain and spinal cord. Tumors made up of leukemia cells can happen on the skin or in other parts of the body.

6 Liver: Liver cancer doesn't often spread outside the liver. It spreads within the liver as it becomes advanced. If it does spread, it is most often to the lungs or bones. Lung: Lung cancer can spread to almost any organ of the body, but most often it will spread to the adrenal glands, liver, bones, and brain. It can spread to the other lung. Lymphoma: Lymphoma tends to stay in the lymph nodes, spleen, and bone marrow. Some start in other organs like the brain or stomach. Others only spread to other organs when they are far advanced. Some lymphomas actually start in other organs, such as the brain or stomach, and may spread from there. Melanoma: Melanoma can spread anywhere in the body. It first tends to spread to nearby lymph nodes, but can then spread through the blood to the brain, lungs, liver, and bone. Mouth and throat: Cancers of the mouth, throat, or nose tend to stay in the same area. When they spread, it is most often to the lungs. Less often they may spread to the liver or bones. Multiple myeloma: Multiple myeloma can cause tumors called plasmacytomas. These tumors can spread to the bones anywhere in the body, but they rarely spread to other organs. Ovary: Advanced ovarian cancer most often spreads to the lining and organs of the belly (abdomen). This can cause a build-up of fluid and swelling. It can also spread to the outer lining of the lungs and cause fluid to build up there. As it becomes more advanced, it may spread to the lung and liver, or, rarely, to the brain or skin. Pancreas: Pancreatic cancer mainly stays in the belly (abdomen). It tends to grow into nearby tissues and may spread to the liver. It can also spread to the lungs. Prostate: Prostate cancer usually goes to the bones when it spreads. Much less often it will spread to other organs, including the lungs and liver. Stomach: Stomach (gastric) cancer tends to spread nearby and within the belly (abdomen). It may also spread to the liver or distant lymph nodes. Spread to the lungs, bones, and brain is less common. Can advanced or metastatic cancer be prevented? For now, the only sure way to prevent the spread of a cancer is to find the cancer early and remove or destroy it. The American Cancer Society recommends certain screening tests to find cancers of the breast, colon, and cervix. But many people don't know about or don't get these tests. And because these tests aren't perfect, some cancers can spread before they are found. There are also many cancers that can't be found early by any of the tests we now have. Scientists are looking for ways to keep cancer from spreading. For instance, certain drugs can be given after surgery to kill cancer cells that might have broken away from the first tumor. This lowers the risk that the cancer will come back.

7 How is advanced cancer found? Some types of cancer are more likely to spread than others. But it's hard to know who will get metastatic or advanced cancer. One way is to look at the cancer cells under a microscope. This process is called grading the cancer. The more normal the cells look, the less likely it is that they will spread. Another way is to look at the size of the tumor. A larger tumor is often more likely to have spread. Also, if the cancer has spread to the lymph nodes, it is much more likely to have spread to other parts of the body, too. Sometimes the lymph nodes are removed during surgery to see if there are cancer cells in them. But even when these things are known, doctors aren't always sure whether a person's cancer will spread or whether they already have advanced cancer. So the doctor will probably do a complete physical exam and some other tests to try to find the answer. Signs and symptoms Signs and symptoms of advanced cancer can include: Loss of energy and feeling tired (fatigued) and weak. This can get so bad that you may have a hard time doing daily tasks like bathing or getting dressed. People with advanced cancer often need help with these things. At some point, patients may spend much of their time in bed. Note that some cancer treatments can cause this, too. Weight loss (without trying) Pain, such as back pain (for cancer spread to the spine) or belly (abdominal) pain (for cancer spread to the liver). Shortness of breath is common when a cancer has spread to the lungs. Advanced cancers can also cause many other symptoms, based on the type of cancer and where it is has spread. For more about symptoms, please see the section, "Managing symptoms of advanced cancer." Physical exam The doctor will ask about your symptoms and do a physical exam. As part of the exam, the doctor may look for certain things, such as fluid in your lungs or belly, tumor lumps on or within your body, or a swollen liver. Tests to find advanced cancer Blood tests Certain blood tests can also point to advanced cancer. Blood tests of liver function are often not normal if the cancer has spread to the liver. Some cancers make substances called tumor markers. High levels of these markers on blood tests can be a sign of advanced cancer. For more information, see our document, Tumor Markers.

8 Imaging tests Pictures of the inside of the body (imaging studies) are used to look for advanced cancer, too. Many of the tests used to find advanced cancer may have also been done when you were first diagnosed with cancer. You can learn more about these and other imaging tests your doctor may want you to have in our document, Imaging (Radiology) Tests. You might have: Chest x-rays to look for tumors in the lungs or fluid in the chest CT scans, a special type of x-ray, to look at your organs MRI scans, which use radio waves and strong magnets instead of x-rays to take pictures of your insides PET scans, which use a form of sugar with a radioactive atom that is taken in by cancer cells and shows up on a picture of your insides Ultrasound, which uses sound waves to look inside of your body Radionuclide bone scans, to help show whether the cancer has spread to the bones Biopsy Often when an imaging test shows something that isn't normal, the doctor will want to do a biopsy to find out if it is cancer. This is done by taking a small piece of the tissue and looking at it under the microscope. Usually the biopsy is done by putting a needle into the spot and pulling out pieces of tissue or fluid. In most cases, a biopsy is the only sure way to tell if the cancer has spread. Talk to your doctor or nurse if you have questions about any tests or studies you're going to have. How is advanced cancer treated? This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience. The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor. Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options. Goals of treatment Advanced cancer is not likely to be cured, but it can often be treated. You and your loved ones should be clear about the goal of any treatment you're having. You should know whether the goal is to try to cure the cancer, to let you live longer, or to relieve symptoms. This can sometimes be confusing because the same treatments might be used for all of these reasons. Some people believe that nothing more can be done if the cancer cannot be cured, so they stop all treatment. But often there are treatments that can control symptoms. Relief from symptoms such as pain, blocked bowels, and upset stomach can help maintain or improve your quality of life.

9 You "call the shots" You have the right to make decisions about your treatment. Some people want to get treatment as long as there's a chance it may help. Others decide that the burdens of treatment are not worth the small chance of benefits. Some people want to stay at home. Others choose to go to an assisted living center, a nursing home, or a hospice. This is a very personal issue. You should make the choices that are best for you. No matter what you decide, you should feel as good as you can for as long as you can. Treatment choices for advanced cancer depend on where the cancer started and if and how much it has spread. As a rule, cancer that has spread will need treatment that goes throughout the body. This is called systemic treatment and examples are chemotherapy ("chemo") and hormone therapy. Surgery for advanced cancer Surgery is most often used for cancer that is confined to one area. It is not often used in treating advanced cancer, but it may be used along with other types of treatment if there are only a few small tumors. Surgery may be used in these ways: To relieve symptoms and improve your life: Surgery can help you feel better and may even help you live longer, even when cancer has spread too far to be cured. For example, cancer can sometimes block the bowel. This can be very painful. A surgeon may be able to bypass the blockage so the bowel can work normally again. And sometimes, simple surgery is used to put feeding tubes in place or to put small tubes into blood vessels for giving drugs to relieve pain. To stop bleeding: Surgery may be done to stop bleeding from the stomach or bowel. To stop pain: Sometimes a tumor may be pressing on a nerve. Or a tumor may be too close to the spinal cord. Either cutting the nerve or taking out the tumor may relieve the pain. To prevent broken bones: Cancer that spreads to bones may weaken them, causing breaks that tend to heal very poorly. If a bone looks weak, surgery may be done to put in a metal rod to support it and prevent a break. If the bone is already broken, surgery can quickly relieve pain and help the person be more active. Whether surgery will be used depends a lot on your overall condition. Major surgery is hardly ever helpful for someone who cannot get out of bed. On the other hand, surgery may be a good idea for someone who is feeling fairly well and is active. Ablative methods for advanced cancer Putting a needle or probe directly into a tumor and using heat, cold, or a chemical to destroy it is called ablation. It is used most often for cancer spread to the bone or liver, but may be used in other areas, as well. It is most often used when only a few tumors are causing problems. A common type of ablation called radiofrequency ablation (RFA) uses a needle that carries an electric current. The tip of the needle is put into the tumor. Ultrasound or CT scans may be used to be sure the needle is in the right place. An electric current passed through the needle heats the

10 tumor to destroy it. RFA is usually done while the patient is under general anesthesia (deeply asleep and not able to feel pain). In another type of ablation, called cryoablation, a probe put into the tumor is used to freeze it, killing the cancer cells. Other methods use heat (laser-induced interstitial thermotherapy) or alcohol to kill the cells. Radiation for advanced cancer Radiation is the use of high-energy x-rays to kill cancer cells or shrink tumors. For cancer that has not spread too far or too much, radiation can sometimes cure the cancer, either by itself or along with other treatments. In advanced cancer, radiation is often used to shrink tumors to reduce pain or other symptoms. This use called palliative. Radiation therapy can be external (given from a machine outside of the body) or internal (putting small radioactive seeds inside the body). Some radioactive materials are made into liquids that can be given into a vein. They go through the blood to areas of bone that contain cancer. The radiation then kills cancer cells and relieves bone pain, but it does not cure the cancer. This type may be used if the cancer has spread to many bones. Sometimes different types of radiation are used together. The main side effects of radiation are tiredness (fatigue) and skin that may look and feel sunburned. There can be other side effects, too. To learn more, please see Understanding Radiation Therapy: A Guide for Patients and Families. Drug treatment for advanced cancer Several types of medicines can be used to treat advanced cancer. Chemotherapy (chemo) Chemo is the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they go throughout the body. This makes chemo a good treatment for cancer that is widespread. Shrinking the cancer can relieve symptoms and may help you live longer. While chemo drugs kill cancer cells, they can also harm some of the normal, healthy cells in your body. This can cause side effects, such as: Nausea and vomiting Loss of appetite Hair loss (the hair grows back after treatment ends) Mouth sores Increased chance of infection (from low numbers of white blood cells) Bleeding or bruising after small cuts or injuries (from low numbers of platelets) Tiredness (from low numbers of red blood cells)

11 Weakness Your doctor or nurse can suggest ways to ease these side effects. It is important to balance any side effects against the symptoms you are trying to relieve. To learn more about chemo, please see Understanding Chemotherapy: A Guide for Patients and Families. Targeted therapy Targeted therapy is a newer type of cancer treatment that uses drugs to attack the inner workings of cancer cells while doing less damage to normal cells. Most targeted cancer therapies do not damage bone marrow or blood cells the way many standard chemo drugs do. But even though they mainly target the cancer cells, these drugs are not perfect they can cause side effects and sometimes bad reactions. Hormone treatment Hormone treatment is the use of drugs to stop the effect of certain hormones that cause cancer cells to grow. For example, estrogen (a hormone made by women's ovaries) can cause certain types of breast cancers to grow. Male sex hormones, such as testosterone, help most prostate cancers grow. Drugs can be given that block the action of these hormones or reduce the amount that is made. Side effects depend on the type of hormone therapy used, but can include hot flashes, blood clots, and loss of sex drive. Immunotherapy Immunotherapy is treatment that boosts the body's immune system or uses man-made versions of immune system proteins to kill cancer cells. Several types of immunotherapy are used to treat patients with advanced cancer. Some of these have been used for a while, but others are still experimental. These treatments are discussed in detail in our document called Immunotherapy. Drugs to treat cancer spread to the bones Some types of drugs can be especially helpful if cancer has spread to the bones. (For more information, see our document, Bone Metastasis.) Bisphosphonates: Bisphosphonates are a group of drugs that work by slowing down the action of bone cells called osteoclasts. These cells normally dissolve small bits of bones to help remodel them and keep them strong. But osteoclasts are often too active when cancer spreads to the bones, which can cause problems. These drugs also have side effects that must be taken into account. The most common side effects are fatigue, fever, nausea, vomiting, and bone or joint pain. Some patients have damage to their jawbone, known as osteonecrosis of the jaw (ONJ), which can be quite painful. This seems to happen most often in patients who have dental work while taking the drugs. For that reason, many doctors have their patients get a thorough dental check-up before they start bisphosphonate treatment. Also, these drugs can cause kidney damage, and should not be given to people with severe kidney problems. To learn more, see our document called Bone Metastasis.

12 Denosumab (Xgeva ): This is another drug that can help when cancer spreads to bone. Studies have shown that it can help prevent problems like fractures in patients with bone metastases. Like the bisphosphonates, denosumab can cause ONJ, so you should take the same measures as mentioned above (such as having tooth and jaw problems treated before starting the drug). Unlike the bisphosphonates, this drug is safe to give to patients with kidney problems. Radiopharmaceuticals: This group of drugs has radioactive elements. The drugs are put into a vein and settle in areas of bone that contain cancer. The radiation they give off kills the cancer cells and relieves some of the pain caused by bone metastases. If cancer has spread to many bones, these drugs often work better than trying to aim a radiation beam at each affected bone. The major side effect of this treatment is lower blood cell counts (mainly white blood cells and platelets), which could put you at increased risk for infections or bleeding. This is more of a problem if your counts are already low before treatment. Advanced cancer clinical trials You may have had to make a lot of decisions since you've been told you have cancer. One of the most important decisions you will make is deciding which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you. Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures. If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at or on our Web site at You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll-free at CANCER ( ) or by visiting the NCI clinical trials Web site at There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it. Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone. You can get a lot more information on clinical trials, in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number and have it sent to you. Advanced cancer complementary and alternative therapies When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites may offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

13 What are complementary and alternative therapies? It can be confusing because not everyone uses these terms the same way, and they are used to refer to many different methods. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor's medical treatment. Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some examples of methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not to be helpful, and a few are even harmful. Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may be harmful, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help. Finding out more It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with few or no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer. As you think about your options, here are 3 important steps you can take: Look for 'red flags' that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a 'secret' that requires you to visit certain providers or travel to another country? Talk to your doctor or nurse about any method you are thinking of using. Contact us at to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at. The choice is yours Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful. Managing symptoms of advanced cancer This section describes many of the major problems that can happen with advanced cancer. You may have some of these problems or none of them. The section after this called "Problems grouped by where the cancer is," outlines problems that are linked to certain types of cancer.

14 Blocked bowel (bowel obstruction) When cancer blocks any part of the intestine, stool can't move through. Symptoms of blocked bowel include bad cramps, pain, and vomiting. This problem happens most often with cancers in the belly or pelvis. Treatment: It is often very had to solve this problem with surgery because many patients are too sick to have surgery. Others may have cancers that are so advanced that even if they can have surgery, it may not help for long. The decision to have surgery should be weighed against the chance of returning to a comfortable life. An operation called a colostomy may help if only the colon is blocked. In this operation the surgeon cuts the colon above the blockage. The cut end is then hooked up to a hole (stoma) on skin of the belly. Bowels can then empty into a bag that is put around the opening. If the bowel is blocked in only one place, a small, stiff tube called a stent may be put through the blocked area to keep it open. Treating only the symptoms is often the best choice. For example, doctors might remove the stomach contents through a tube put in through the nose (called a G tube). This often relieves nausea and vomiting. You would also need to stop eating, and drink only small amounts to relieve thirst. Medicines for pain and nausea can be given as a shot or patch. Broken bones Cancer can sometimes weaken bones which can lead to breaks (fractures). This happens most often in the leg bones near the hip. There can be very bad pain for a while before the bone breaks. At that time, an x-ray may show that the bone is likely to break. Treatment: If possible, it's best to prevent the break. This can be done by putting a metal rod through the weakened part of the bone. If the bone has already broken, something else will be done to support the bone. Radiation treatment might also be given to prevent more bone damage. If bones of the spine (the vertebrae) are fractured, vertebroplasty may be used to support them. To do this, a type of bone cement is injected into the damaged bones. Falls are also a danger for weakened bones. Medicines or the cancer itself might cause confusion, weakness, or dizziness which can lead to falls and accidents. Talk your doctor about walkers, shower chairs, or other things that might help you. Confusion People with cancer that is getting worse often become restless, anxious, depressed, or angry. The person may look sleepy and not respond to questions one minute but be wide awake and alert the next. They may see and hear things that are not really there and say things that don't make sense. Tell the doctor about these symptoms, since this kind of confusion can often be treated. Many different things can cause confusion: Liver disease Bowel blockage (obstruction)

15 Bladder blockage Medicines Medicine withdrawal Low blood sugar Cancer that has spread to the brain Infection Pain Blood chemistry changes, such as too much calcium Treatment: There are many ways to treat confusion, but the best approach will depend on the cause. A physical exam will be done and imaging tests may be done, too. Blood tests may be done to look at how well the organs are working. Medicines, especially pain medicines, may need to be changed to see if the confusion gets better. Constipation Constipation is when stool gets hard and dry, and you have trouble passing it out of your body. It can be caused by many of the changes that go along with advanced cancer like: Medicines (mostly those taken for pain) Diet changes, like eating and drinking less Not being as active Changes in the blood like too much calcium or too little potassium Treatment: It is best to prevent constipation when possible. Talk to your doctor about taking laxatives before the problem starts. Be sure to drink enough liquids and get plenty of fiber. Keep up easy exercise like short walks or even chair exercises. If you don't respond to treatment, your doctor may need to look for other, more serious causes of constipation, such as pressure on the spinal cord or a blocked bowel. Depression Feeling sad and down at times is normal with cancer and the side effects of treatment. But there is room for happiness even with advanced cancer. You don't have to feel down all the time. Depression can be a very serious problem, but it can be treated. Talk to your doctor if you feel down or depressed. A trained mental health professional may be able to help you feel better -- no matter what is causing you to feel depressed. Clinical depression is more than being sad. It can cause great distress and calls for medical care. Most depression can be treated. The symptoms of depression are listed below. Patients, family and friends should watch out for the symptoms listed below.

16 Symptoms of clinical depression include: Ongoing sad or "empty" mood Feeling hopeless and helpless No interest or pleasure in everyday things Less energy, feeling tired, being "slowed down" Trouble sleeping, early waking, or oversleeping Loss of appetite or overeating Trouble with thinking, memory, or making decisions Feeling guilty, worthless, or helpless Feeling grouchy Crying a lot Thoughts of suicide; trying to kill yourself Please see a mental health professional if you have 5 or more of these symptoms for 2 weeks or longer. Family members and friends should also encourage a patient with these symptoms to get help. Treatment: Several types of treatment may be helpful, like: Medicine Counseling Social activities Learning new problem-solving skills People treated for depression are often surprised at how much better they feel. You can find out more in our document called Anxiety, Fear, and Depression. Tiredness (fatigue) Tiredness is one of the most common symptoms among cancer patients. It is a physical, mental, and emotional tiredness that does not get better with rest. Tiredness can be caused by: The cancer itself Cancer treatment Not eating well or getting enough fluids Pain Depression

17 Not having enough red blood cells (anemia) Treatment: Treatment is aimed at the cause of the tiredness. Blood transfusions can help some people who have low red blood cell counts. There are also medicines that help the body make more red blood cells. Light or medium exercise with a lot of rest breaks in between can often help. You can save energy by doing what needs to be done first and letting other things wait. Spread your tasks throughout the day rather than trying to do them all at once. Sometimes stimulant drugs can help, too. For more information please see our documents Anemia in People With Cancer and Fatigue in People With Cancer. Too much calcium in the blood People with advanced cancer may have too much calcium in their blood, usually because of cancer in the bones. Early symptoms include: Constipation Passing urine very often Feeling sluggish Feeling thirsty all the time and drinking large amounts of fluids Late signs can include muscle weakness, muscle and joint aches, confusion, coma, and kidney failure. Treatment: Giving fluids and certain drugs can quickly bring blood calcium down Treating the cancer itself can also sometimes help treat the calcium problem. But if the cancer can't be treated, calcium levels may rise and have to be treated again. Nausea and vomiting Nausea and vomiting can be caused by the cancer itself or by cancer treatments like radiation or chemo. Often the problems get better after treatment ends. Nausea can also be caused by some pain medicines. This usually gets better as your body gets used to the drug but can also be helped with medicines. Constipation can also lead to problems with nausea, so preventing and treating constipation is very important. Treatment: There are medicines that can help. Ask your doctor about these. Also, there are many things you can do on your own. Here are just a few ideas. To find out more, please see our document, Nausea and Vomiting. For nausea Try bland foods like dry toast, crackers, etc. Drink plenty of liquids. Try ice pops, gelatin, broth, or cold clear liquids. Eat several small meals and snacks if you get sick only between meals. Eat things that smell good like lemon drops or mints.

18 Eat food cold or at room temperature to make the smell and taste weaker. Ask the doctor about medicines to help with nausea and use them as directed. Do not wait until the nausea is bad before taking a drug to fight it. Try to rest quietly with your head up for at least an hour after each meal. Learn to relax or meditate. Distract yourself with soft music, a favorite TV program, or company. For vomiting If you are in bed, lie on your side so that you won't breathe in or swallow your vomit. Ask your doctor about medicines to help with vomiting and use them as directed. Sometimes taking a medicine by mouth can bring on nausea or vomiting. Your doctor may be able to order your medicines in a different form instead. Some can be taken as suppositories (drugs that you take through your rectum), skin patches, or gels that are put on the skin. Learn to relax or meditate. Eat ice chips or frozen juice chips that you can munch on slowly. Things to avoid Don't force yourself to eat or drink when you have an upset stomach or are vomiting. Don't lie flat on your back. Stay away from foods that have strong smells. Don't eat foods that are sweet, fatty, salty, or spicy. Stop eating for 4 to 8 hours if you are vomiting a lot, then try small amounts of clear liquids. Call the doctor if you: Breathe in or swallow vomit Throw up more than 3 times an hour for 3 hours or longer See blood or something that look like coffee grounds in your vomit Can't keep down more than 4 cups of liquid or ice chips in a day Can't eat for more than 2 days Can't take your medicines Feel weak or dizzy

19 Pain Many people with advanced cancer have pain. Getting relief from pain is important. Not only will it help you feel better, but it will also make it easier for you to focus on the things that are important in your life. Some studies show that cancer patients who get good pain relief may live longer than those who don't. The first step is to let your cancer care team know about your pain. The best treatment for you depends on the type of pain you are having and how bad it is. See the tips below. For more details, see Pain Control. Treatment: Sometimes pain is relieved by treatments that kill cancer cells or slow their growth (for instance, chemo or radiation). But pain medicine taken by mouth is the most common way to treat pain. Often 2 or more drugs are used together. Your doctor will usually start with mild drugs like acetaminophen (Tylenol ) or ibuprofen (Motrin ). If these aren't helping you will probably be given an opioid such a codeine, hydrocodone, morphine, or oxycodone. Unless you have a history of drug or alcohol abuse, you can take these drugs without being concerned about getting addicted. These drugs may have their own side effects, such as making you drowsy or constipated. With all pain medicines, it is important to take the medicine regularly. You need to keep enough of the medicine in your bloodstream to control the pain. This way the pain won't become so bad that you will have to take more than you would normally need to get it under control. Doctors have learned that not all people respond to medicines in the same way. If one pain medicine isn't helping you, talk to your doctor about trying another one. There are many other ways to relieve pain, too. Massage, heat and cold, changing body position, and distraction are just a few. To learn more about how to manage pain, please see Pain Control. Skin problems People with cancer may have skin problems from sitting or lying too long in one position. Or problems can result from not eating well, not being able to move around, swelling, or from cancer treatments. Treatment: Your doctor can recommend a skin care program to fit your needs. The most important things are to change positions often when you are sitting or lying down and to keep your skin clean and dry. Pressure on the spinal cord Cancer sometimes spreads to the bones in the spine. This can put pressure on the spinal cord. Symptoms can include bad back pain, numbness, weakness, or trouble passing urine. Tell your doctor right away if you have any of these symptoms. Pressure on the spinal cord can be very serious and treatment should begin right away. Early treatment can help reduce long-term nerve damage and prevent paralysis (not being able to move). Treatment: Steroids can be given to bring down swelling and treat pain. Radiation can shrink the tumor. Sometimes surgery is used to remove all or part of the tumor.

20 Blocked blood flow to the heart Pressure from tumors in the chest or lungs can block blood flow through the vein that returns blood to the heart. This will cause blood to back up in the lungs, face, and arms (superior vena cava syndrome). Symptoms include: Shortness of breath A feeling of fullness or pressure in the head Swelling in the face, neck, and arms Coughing Chest pain Facial redness Swollen neck veins If not treated, this can affect blood flow to the brain, which can cause confusion, changes in consciousness, or even coma. Treatment: Radiation or chemo can help shrink the tumor. If these are not options, you may have a metal tube (stent) placed into the vein. The tube is threaded in through a vein in the arm or neck and then pushed through the blockage. Trouble breathing Trouble breathing can be caused by a buildup of fluid around the lungs, very low red blood cell counts, or a tumor blocking an airway or major blood vessel. Treatment: Treating the cause, if it can be done, will help the problem. Sometimes radiation is used to shrink a tumor in the lung. Removing fluid from around the lung may help if that is the problem. Oxygen can be very helpful. It is given through a small tube the goes under your nose. Opioids, like morphine, are the best drugs to relieve the feeling of shortness of breath. Having trouble breathing can make you feel anxious, worried, or even like you are in a panic. Drugs for anxiety, such as diazepam (Valium ) can help. Some people find that things like relaxation methods, biofeedback, or other complementary techniques are useful. Weight loss and not eating well As cancer gets worse, many people feel weak, don't feel like eating, and lose a lot of weight. This is often caused by the cancer itself and is not within the patient's control. Patients may want to eat in order to help themselves, but they cannot force themselves to eat. And even if they do eat, they may keep on losing weight. Treatment: It is very hard to treat this problem. Getting nutrients through a feeding tube can be uncomfortable and is not always helpful. Feeding through a tube (IV or a stomach tube) rarely

21 helps. Sometimes the best thing you can do is to eat smaller amounts of high-calorie foods more often. One drug that has been helpful is megestrol (Megace ). In high doses, it can bring back appetite in some patients. There are other drugs that might help improve appetite, too. Nausea, constipation, and depression can also lead to poor appetite. Treating these problems can also help. Problems grouped where the cancer is This section covers the symptoms you might have when cancer spreads to different places in the body. Not everyone will get all the symptoms. Treatment is covered only briefly. More details about treating a given symptom can be found in the section "Managing symptoms of advanced cancer." If the cancer is in the belly (abdomen) Ascites Fluid build-up in the belly (abdomen) is called ascites. This extra fluid can be uncomfortable and make it hard for you to breathe. Treatment: The fluid can be removed through a needle, but it will likely come back and may need to be drained many times. If the fluid keeps coming back, sometimes a catheter (a small, flexible tube) can be put through the skin and left in place. That allows the fluid to be drained off without having to use a needle. Blocked bowel Cancer that has spread to the bowels and grown large can cause the bowel to be blocked (obstructed). This causes very bad cramping pain and vomiting. Treatment: Colostomy or bypassing the blockage with surgery can help if you are strong enough to have surgery. Placing a stent (hard tube) inside the intestine may also help keep it open. Kidney blockage Cancer can also spread to or block the thin tubes that carry urine from the kidneys to the bladder. If this happens, you may stop passing urine. The urine backs up to the kidneys, causing them to stop working. This often makes you feel very tired and sick to your stomach. Treatment: In many cases, a tube (stent) can be threaded through the ureters to hold them open and allow urine to flow again. Another option is placing a tube right into the kidney to allow the urine to drain into a bag outside the body. This is called a nephrostomy. If the cancer has spread to bones Cancer spread to bone is sometimes found with x-rays or other imaging tests before symptoms occur. This is often treated with a bisphosphonate or denosumab (Xgeva) to help prevent (or delay) problems.

22 Pain The main symptom of cancer in the bones is pain. Sometimes the bones will weaken and break. Treatment: Drugs or radiation can be given to make the bones stronger or slow the damage caused by the cancer cells. A weak bone may need a rod put in to support it. Broken bones Sometimes a bone will weaken and break. This most often happens in bones that support your weight, like the thigh bones. But it can also happen to the bones in your back. To lower the risk of falls or broken bones Use a cane or walker as needed to keep you steady. When you need it, ask for help walking. Keep walkways clear. Ask your doctor about drugs that strengthen bones Do not change positions quickly. This can cause dizziness or unsteadiness. Sit on the side of the bed for a minute or so before standing up. Wear rubber soled slippers or shoes when walking or standing. Stay away from activity that is hard on your bones (like heavy lifting or jogging). Very weak bones may need a rod put in by a bone surgeon to strengthen the bone. If a bone has already broken, then something will need to be done to support the bone. High blood calcium levels When cancer spreads to the bones, it can cause calcium to be released, leading to too much calcium in the blood. This is discussed in more detail in the section called "Too much calcium in the blood" under Managing symptoms of advanced cancer. Treatment: IV fluids and bisphosphonate drugs may be used to bring down blood calcium levels. If they don't work, other medicines may be used. Pressure on the spinal cord If cancer spreads to the bones of the spine, it can put pressure on the nerves in the spinal cord. Early symptoms can include back pain and leg weakness. The pressure on the spinal cord can cause problems passing urine or even trouble passing stool (so that the person feels constipated). If left untreated, the leg weakness can turn into paralysis, which can be permanent. Treatment: Steroid medicines are used to reduce spinal cord swelling. Radiation treatment is often used to shrink the cancer, and sometimes surgery is needed to remove cancer and to make the spine more stable.