Breast Cancer Treatment Protocol

>> operator: listen-only mode. after the presentation, we will conduct a question-and-answer session and if you have a question, please press the star one. today's conference is being recorded. if you have any objections ,

you may disconnect at this time. i would like to introduce your host for today's conference, ms. candace maynard. you may begin. >> candace maynard: great. thank you and welcome for joining us today as we kick off our second

session in our four-session pilot of educational seminars designed to provide the content, tools, and resources necessary for public health professionals to address cancer as a public health problem. my name is candace maynard and i'm with the national cancer

institute's office of communications and education. today's seminar, understanding cancer, treatment and survivorship, will include an overview of factors that influence cancer treatment, side effects, and challenges faced

by cancer survivors. we have a variety of different skill levels in our audience today and intend [inaudible] material to be presented to be basic so as to lay the foundation for more advanced concepts, to be presented

in future sessions. [ background noise ] it is my pleasure to introduce our presenter for today, ms. annette galassi. annette is a public health advisor in the national cancer of communication and education. ms. galassi is a registered

nurse by training and received her bachelor of science degree in nursing from the state university of new york at albany, and her master of arts degree in advanced nursing science from new york university. her career began

as a staff nurse in medical oncology at memorial sloan-kettering cancer center where she was also clinical nurse specialist. ms. galassi moved to the washington d.c. area in 1986 and was the clinical

nurse specialist of the clinical center at the national institutes of health. during that time, she completed a post master's certificate as an adult nurse practitioner at the university of maryland.

in 1993, ms. galassi joined the faculty of georgetown university's lombardi cancer center where she was their first oncology nurse practitioner, and cared primarily for women with breast cancer. ms. galassi returned to government service in 1998,

joining the national cancer of communications where she oversaw the training program for the cancer information service. she currently works in ncis office of communications and education and the office of partnership

and dissemination initiatives. ms. galassi is a member of the oncology nursing society, the american society of clinical oncology, the international society of nurses and cancer care, and the international association

of clinical research nurses. i have just a few quick housekeeping items before i turn things over to our presenter. the archive for today's session will be posted to the education and training tools for health professionals page

located on cancer.gov next week. we invite your questions throughout today's presentation. you can post questions live through the operator by pressing star one on your telephone. you will then be placed in a queue for the live q

and a session at the end of today's call. you can also submit questions via the q and a tab at the top left of your screen. we will get to as many calls and questions today as we can, and we'll alternate between online

and live operator-assisted questions. and without further ado, today's presenter, ms. annette galassi. >> annette galassi: thank you, candace. i hope that those of you that have cancer experience

that are with us today on the webinar, will at least take home one or two new things that you can incorporate into your practice and i hope that you'll perhaps learn about some nci resources that you didn't know

about before, that you can use with your patients or in your work with your community. the objectives for today's webinar are on the slide before you. and basically, what i'm going to do in our hour together is

review the general principles of cancer treatment. i'm going to briefly review each type of treatment and its major side effects and i'll highlight the nci resources by type of treatment. now, i'm going to touch upon the issue

of cancer survivorship. so let's start with cancer treatment. and the major cancer treatment modalities include surgery, radiation, chemotherapy, biologic therapy, targeted therapy, and hormonal therapy.

and, in practice, really, most cancers are treated using more than one of these treatment modalities. and i thought we might use breast cancer as an illustration of this principle. so, for example, a woman with early-stage breast

cancer might undergo a modified radical mastectomy or have a lumpectomy with sentinel lymph node biopsy or an axillary lymph node dissection. if she has undergone a lumpectomy, she'll also receive radiation

therapy to the breast, or if she has multiple lymph nodes that are positive, she may also receive radiation therapy to the axillary area. most women with early-stage breast cancer will receive adjuvant chemotherapy and this is given in addition

to surgery to reduce the risk of recurrence of cancer elsewhere in the body. if the tumor is her2-positive, her2 standing for the human epidermal growth factor receptor. if it's her2-positive, then, the adjuvant chemotherapy may

also include pertuzumab or herceptin which is a targeted therapy. and finally, if the tumor is estrogen and progesterone receptor positive, the woman might also be treated with hormonal therapy, using either a

selective estrogen receptor modulator like tamoxifen or an aromatase inhibitor such as, anastrozole. so, as you can see, this woman with early-stage breast cancer really has treatment using almost every single one of these

treatment modalities. and her treatment team is likely to include a variety of healthcare providers. the surgeon usually performs the biopsy and does the definitive surgery. occasionally, an interventional radiologist

might also do the biopsy. the radiation oncologist is responsible not only for developing the patient's radiation treatment plan, but he or she also determines the exact area that will be treated, the total dose

that will be delivered to the tumor, how much of that does is permissible to be given to the surrounding healthy tissue, and he or she will also determine the [inaudible] at which to administer the

radiation therapy. the medical oncologist is responsible for overseeing the chemotherapy, or hormonal therapy regimen that will be given, and also manages both side effects and toxicity from treatment.

and many medical oncologists also, assume responsibility for the patient's general medical care while that patient is undergoing active treatment and only turns the general medical care back to the primary care provider

at the end, of the active treatment phase. at academic medical centers and at comprehensive cancer centers, many medical oncologists are actually subspecialists. so they'll see only patients with gastrointestinal

malignancies or genitourinary malignancies, or thoracic malignancies. also, in these settings, there might be multi-disciplinary teams where patients can go and see a variety of physicians at one time and come away

from that interaction with recommendations for a treatment plan. the oncology nurse is also an integral member of the treatment team, and not just because he or she is responsible for the administration

of chemotherapy and targeted therapy, but really the oncology nurse is also the individual that in many respects is for teaching the patient about their disease, about their treatment, about the side effects

that they may anticipate and ways in which, they can manage those side effects. there's also a social worker, a chaplain or various therapists that may comprise part of the patient's treatment team. so let's talk

about some general principles of treatment. and what treatment or treatments the patient receives really depends on a variety of factors. first of all, the type of cancer that the patient has. solid tumors such as blast

or colon cancer are often initially treated with surgery, whereas, hematologic such as leukemia are treated with chemotherapy. the size and the location play a role. a large primary tumor might first be treated

with chemotherapy to shrink them and make them more operable and this is referred to as neoadjuvant therapy. and, in terms of location, thinking back to my practice and how things were when i started in oncology, clinicians made treatment

decisions really primarily based upon the location of the tumor and how those cells looked under the microscope. like this really is rapidly changing in this era of genetic and genomics and in some cancers, molecular diagnostics are being

increasingly used to identify patterns of gene expression and this information is being factored into treatment decisions. let me give you a couple of examples of that. for example,

in patients with non-small cell lung cancer, in some treatment settings the tumor is being tested for the presence of an egfr mutation. egfr standing for the epidermal growth factor receptor and the patient's

tumors are being treated -- i'm sorry, being tested for a mutation to determine whether this individual should be treated with an egfr-tyrosine kinase inhibitor or whether chemotherapy is the appropriate first-line treatment.

for women with node-negative estrogen receptor positive breast cancer, oncotype dx is being used to more precisely estimate a women's risk of cancer recurrence, and to guide the physician in making the decision regarding

whether to recommend adjuvant chemotherapy or whether hormonal treatment will suffice in that situation. so we're learning more and more about the specific molecular characteristics of tumors and that is beginning to play a role

in treatment decisions made by clinicians. the stage of the disease will also factor into the kind of treatment that the patient receives. a newly diagnosed patient with a very small colon cancer would most likely be treated

with surgery whereas, a patient with metastatic colon cancer that has spread to the liver would most likely be treated with chemotherapy. the general health of an individual also plays a person with multiple underlying medical conditions

such as chronic obstructive pulmonary disease or congestive heart failure might not be the best candidate for surgery or for an aggressive chemotherapy regimen and so the general health and other medical problems

that that individual has will factor into the treatment decision. there are also logistic and social issues that very often come into play in practice. those of us that are privileged to live in an urban area have

easy access to radiation therapy facilities, and can comfortably make a decision whether to have a modified radical mastectomy or whether to have a lumpectomy and radiation therapy as treatment

for early-stage breast cancer. but if i live in a very rural part of the united states, where perhaps, it would take me two hours to get to a radiation therapy facility and i'm looking at making that trip, you know,

two hours each way every day for several weeks, i might have to think twice about whether and whether it might just make more sense for me to undergo a mastectomy, instead. for most cancers, treatment usually begins

within six weeks of diagnosis. and this gives patients plenty of time to go and get a second opinion and think about their treatment options. but there are some situations where treatment needs to start immediately

such as patients that have high-grade lymphomas or patients with acute leukemia. at the other end of that spectrum, if you will, there are cancers such as very low-rate prostate cancer, where there is strong evidence to support what we used

to call watch and wait and what we're now calling active surveillance. and what this means is that, the man will undergo semiannual exams and annual prostate biopsies and treatment doesn't begin until this is a rise in the psa,

or a rise in the gleason score of the tumor, or if the patient develops symptoms. so there are some situations where, as i said, we have either extreme; treatment needs to be started right away

or we're in an active surveillance mode. the goals of treatment can vary. often the goal, of course, is to cure the cancer, but in some cases, the goal is to control the disease for as long as possible.

and this is happening increasingly with cancer. it's becoming more of a chronic disease, and it's not the death sentence that it once was when it had spread beyond the area of the initial tumor. treatment can also be given

to reduce symptoms and this is known as palliative therapy. the other thing about treatment is that the treatment goals may change over time. you know, like at the point of initial diagnosis,

the focus might be on cure. at the point when a patient develops recurrent disease the focus shifts, appropriately so, to control. so treatment is usually quantified as local or systemic. and by local we mean treatment

that affects cancer cells in the tumor and in the surrounding area and examples of that are surgery and radiation therapy. and by systemic treatment we mean treatment that travels through the bloodstream and throughout the body

and reaches cancer cells in a variety of locations, and examples of that are chemotherapy, so let's spend some time looking at each of the treatment modalities and i'm going to begin with surgery, and surgery is really the oldest

form of cancer treatment. and when the goal is cure, the object really is to remove the tumor and a small margin of surrounding tissue to make sure that we have gotten all of the cancer.

regional lymph nodes are also removed and that can be done in a procedure called a lymph node dissection where a group of lymph nodes are removed, or increasingly we're seeing sentinel lymph node biopsies being done. the sentinel lymph node is the

first lymph node to which, cancer is likely to spread and patients may have a sentinel lymph node biopsy in place of having a lymph in either case, the reason why we do lymph node sampling is based on the idea, that cancer metastasizes

in an orderly way, from the primary tumor to the regional lymph nodes and then to distant sites in the body. and lymph node involvement is one of the factors that we use when staging a patient's disease and making decisions

as to whether, additional therapy beyond surgery is required. surgery can remove the tumor and a healthy margin of surrounding tissue, as i explained, or occasionally the entire organ can be removed.

so you can have either the lumpectomy where the tumor is removed and the remainder of the breast is left intact, or you can have the modified where the entire breast is removed. or non-small cell lung cancer patients can undergo a lobectomy

where just one lobe of the lung is removed or they can undergo a pneumonectomy where the entire lung sometimes the tumor is so large that it cannot be completely removed and debulking surgery is done.

and debulking surgery essentially removes as much of the tumor as possible and then the patient is treated with either chemotherapy or radiation therapy. and the reason for doing the debulking surgery is to make the chemotherapy

or the radiation therapy more effective, that's the tumor mass is reduced before initiating treatment with those other modalities. surgery can also be done for prevention. in women that are brca1, brac2-positive,

they may make the decision to have a prophylactic mastectomy. to control symptoms. for example, in the setting of a bowel obstruction and this would be palliative surgery, and finally, reconstructive surgery can be

done following cancer surgery. so let's move on to radiation therapy essentially uses high-energy radiation to shrink tumors and to kill cancer cells. and either x-rays, gamma rays, or charged particles can be used in radiation therapy.

and the way that radiation works is that it essentially kills cancer cells by damaging their dna and it can do this either directly, or by creating charged particles known as free radicals which then, in turn, damage the dna.

radiation can come from a machine outside the body and that's known as external beam radiation, or it can come from radioactive material that's placed inside the body near the site of the tumor and that's called brachytherapy,

or radiation can be given in the form of a radioactive substance that is administered orally or intravenously and travels throughout the blood to the tissues. okay. external beam radiation is given in daily fractions,

monday through friday. so the total dose is usually divided into fractions or small doses that are given daily, monday through friday, for a series of weeks, anywhere from one week to several weeks.

and the reason why we give radiation only once a day and why we take a break on saturdays and sundays is really to minimize the damage to normal tissue and also, to increase the likelihood that cancer is exposed

to radiation at points in the cell cycle when they are dividing and would be most vulnerable to the effects of radiation therapy. radiation can damage some types of normal tissue more easily than others.

for example, the testes and the ovaries are considered extremely sensitive and each type of tissue has a maximum safe lifetime limit dose that can be given to that tissue. so very often

if a patient has already had radiation therapy to an area of their body, they cannot have a second course of radiation to that same site in most instances. and that's also why you'll see patients have very tiny tattoos that mark the borders

of the radiation field so that if they subsequently, are being considered for radiation therapy, the radiation oncologist knows exactly where the previous radiation was administered. okay. internal radiation or brachytherapy is radiation

that's delivered from radiation forces that are placed inside the patient's body and different techniques can be used to deliver brachytherapy. interstitial brachytherapy is radiation -- internal radiation

that is placed within the tumor itself. into the prostate gland for the treatment of prostate cancer. intracavitary brachytherapy is placed within a body cavity near the tumor. it might be placed

within the uterus to treat cervical cancer. the actual radioactive isotope that's used in brachytherapy is sealed in tiny little pellets that are called seeds. and these seeds are then placed in the patient using delivery

devices like needles or catheters. and the radioisotope decays naturally over a period of days or weeks and emits its radiation to damage the cells. and it can either just stay in place and in that case it's a permanent

brachytherapy or a permanent implant or the implant can be removed once the isotope has fully decayed. radiation can also be delivered systemically. radioactive iodine is used for the treatment of some types

of thyroid cancer. radioimmunotherapy can be used and that's the use of a monoclonal antibody that's attached to a radioactive substance and the monoclonal antibody essentially acts as the vehicle to deliver the radiation

to the actual tumor cell. an example of this is zevelan [phonetic] that's used in the treatment of b-cell non-hodgkin's lymphoma. radiopharmaceuticals such as strontium 89 chloride can also be given intravenously

to relieve the pain that's associated with bony metastatic disease and this is considered palliative, a form of palliative so the side effects of radiation therapy are site specific. in another words,

if you receive radiation therapy to the head and neck area, you might experience mucositis, but if you receive it to the cervical area, you'll more likely experience something like diarrhea and vaginal or dryness and redness.

skin changes can occur in the treated area. the skin can become dry, itchy, almost like someone has had a sunburn and fatigue is a very common side effect. here in the nci, resources, or i should say a selection of the nci resources related

to radiation therapy. you can access them either by going to www.cancer.gov and i'll show you how to do that later on in the presentation or you can order them by calling 1-800-4-cancer. what i want to point

out on this slide is the pamphlet on the left. that's actually an audio cd that can be used for patients with low literacy skills. okay. let's shift to chemotherapy. chemotherapy usually refers to the use of cytotoxic drugs

which, effect rapidly dividing cells and, broadly, chemotherapeutic agents tend to fall into two major categories. they are either cell cycle phase non-specific agents, and these are drugs that affect the cells during all

phases of the cell cycle including, during the resting phase. and there are cell cycle phase specific agents that most significantly affect the cells during specific phases of cell division like the s phase or the m phase.

most chemotherapy drugs are not specific to cancer cells. rather they target all rapidly dividing cells. the difference is that cancer cells are unable to repair the dna damage that is rendered by the chemotherapeutic agent

whereby, normal cells can generally repair that damage. so chemotherapy does have the potential to harm healthy tissue especially, those tissues that have a high mitotic rate like the cells that line our gi tract or the cells of our bone marrow.

and this is essentially what causes side effects. chemotherapy is usually given in combination meaning that two or more drugs are given at the same time. and often, cell cycle phase specific and non specific drugs are combined together

in a combination chemotherapy regimen. and we use acronyms for these combinations like cmf which stands for the three-drug combination of cyclophosphamide, methotrexate, and fluorouracil. chemotherapy is given in 21 --

usually 21 or 28-day cycles and this is to allow healthy cells to recover. and adjutant chemotherapy is, again, that treatment that's given to reduce the risk of reoccurrence of the disease coming back

elsewhere in the body, and it's usually given for a specified number of cycles, whereas, when chemotherapy is given in the setting of metastatic disease, it's usually given until we see progressive disease

and then the chemotherapeutic regimen is changed. you can guess what the side effects are going to be thinking about what i just said about rapidly dividing cells. so, by and large, you'll see gi toxicities including nausea, vomiting,

diarrhea, mucositis, bone marrow suppression, including neutropenia which is, a lowering of the white cell count, anemia which is, a lowering of the red cell count and thrombocytopenia which is, lowering of the platelet count. and you'll see alopecia

which is hair loss. and here are some to chemotherapy and on the left you'll see chemotherapy and you, which is really a fabulous publication. if you're not familiar with it you really should take a

look at it. in the center, that is one of the managing chemotherapy side effects fact sheets that we have. we have a whole series of side effect management fact sheets and then

on the right-hand side are a booklet called coping with advanced cancer, and though that's not directly related to chemotherapy, it's a resource that you all might find useful because it discusses palliative care, home care, hospice,

symptom management, as well as, psychosocial and emotional issues. okay. next, we're going to talk about biologic therapy and biologic therapy or immunotherapy is essentially, designed to induce the patient's own immune system

to fight the tumor, to fight the disease. example of this include bcg immunotherapy that's administered intravesicularly or into the bladder of superficial bladder cancer. another example is the use of interferons or cytokines

like il-2 to induce an immune response to treat pneumo [phonetic] cell carcinoma or melanoma. biologic therapy can also be used to limit some of the side effects of cancer treatment and examples of this, the use

of hematopoietic growth factors such as filgastrim or neupogen and epogen or procrit to increase white blood cells and red blood cells counts respectively. okay. next i want to talk about targeted therapies and these therapies really first

became available in the late 1990s, and have had a significant impact on cancer treatment and on the treatment of some specific diseases like cml and gist or gastrointestinal stromal tumor.

unlike chemotherapy which, as we just talked about, can control rapidly dividing cells, target therapies work by interfering with specific molecules that are parts of the signaling pathways and processes used

by cancer cells to grow, to divide, and to spread throughout the body. and targeted therapies can broadly be classified into two groups. either small molecule drugs or monoclonal antibodies. small molecule drugs are drugs

that are able to diffuse into the cell so through the cell membrane and into the cell and they can act on targets found inside the cell. whereas, monoclonal antibodies are too big

to diffuse inside the cell, so that act primarily on targets outside the cell or on the surface of the cell. examples of tyrosine kinase inhibitors, imatinib and that's also called gleevec, of monoclonal antibodies are the her-2 [inaudible] antibody,

trastuzumab or herceptin and the anti cd20 antibody, rituximab, that's used to treat a variety of t-cell lymphomas. and on the visual learner and so for me this is a great slide because it allows me to visualize how chemotherapy

works versus targeted therapy. so we see the dna inside the nucleus of this cell and that's really the target for most chemotherapeutic agents. but targeted therapies can work in a few different places. they can bind

to the growth factors and those are the little purple things that you see floating around on this slide. and an example of that is bevacizumab or avastin which binds to the vascular endothelial grow factor and it prevents

that growth factor from interacting with the receptor on the surface of endothelial cells. and this is important because that's a necessary step in the initiation of the formation of new blood vessels,

a process called angiogenesis, and if you remember if you listened to linda parreco talk a couple of weeks ago, she talked about that process being an important way that tumors grow and metastasize its ability

to lay down new blood vessels. target therapies can also work on those signaling enzymes inside the cell and block the signaling pathway that sends messages to the cell to replicate. and an example of this kind of drug is genitinab [phonetic]

which is also called [inaudible] and it blocks the kinase that's involved in [inaudible] signaling and essentially shuts that off. so targeted therapies, because they're more specific and selective for molecular targets

in the cell or outside the cell than cytotoxic drugs are, they tend to cause little or no damage to normal cells. and so they tend to have fewer side effects. that doesn't mean that they're without side effects, but they tend

to have fewer side effects than, targeted therapies can be given alone. they can be combined together or they can be combined with other treatments. and this is a slide just listing some of the resources that we have focused

on biologic therapies and targeted therapies and i want to call your attention to the advances in targeted therapies tutorial. and this is one of the series of tutorials that are really quite fabulous. with them, they are graphic

rich, self-paced tutorials that are fabulous for healthcare providers or for very sophisticated patients in teaching some of the concepts that we've talked about in this lecture today and in linda's lecture last

time around. the resources, oncology nurses, on the right there is a cd that has several of these tutorials packaged together and can be ordered online. okay. the last treatment that i'm going to talk

about is hormonal therapy and hormonal therapy is primarily used to treat cancers that depend on hormones for their growth. and these are tumors such as some forms of breast cancer or prostate cancer.

many breast cancers depend on estrogen for their growth and by giving a drug such as tamoxifen, which essentially competes with estrogen for binding to the estrogen receptor on the surface of the cell, the growth of that cell can

be inhibited. in prostate cancer, the removing of testosterone is often used as a treatment strategy. and without testosterone, the tumor shrinks and its growth slows. luteinizing hormone releasing hormone, agonists,

or lhrh agonists prevent the testicles from making testosterone and they can be used as a maintenance strategy for prostate cancer. the side effects of hormonal therapy for the selective estrogen

receptor modulators, those side effects include hot flashes and vaginal dryness. the aromatase inhibitors, those are drugs like anastrozole or arimidex and exemestane, omeprazole, these drugs tend to also have joint pain and muscle pain

as their side effects. lhrh agonists and anti-androgens have impotence, hot flashes and loss of libido, as side effects. with the anti-cancer drug information resource, that's the url for it. it has summaries

for individual cancer drugs, as well as, for combinations of drugs that are commonly used in cancer treatment. and when we send out the evaluation for today's webinar, they'll be instructions for how you can sign

up for a listserv that will notify you, when there are new additions to the cancer drug information resource. okay. i'm going to shift gears here now, totally, and talk for a few minutes

about cancer survivorship. and in the last few years, cancer survivorship has come to the forefront because, we're actually making progress in the treatment of cancer. in many cases, cancer is no longer a terminal disease.

it really is a chronic illness and is being managed as a chronic illness just as hypertension and diabetes are chronic illnesses that need management. there are over 11 million cancer survivors here in the united states.

there are 20 million cancer survivors globally. three out of four families have at least one family member who has been diagnosed with cancer. and [inaudible] rapidly growing population of cancer survivors and it's really becoming a

public health issue. the majority of cancer survivors are over 65 and the diseases that survivors have mimic the most common solid tumors, breast, prostate, and colorectal cancer. so who is a cancer survivor?

well, when i started practice all those years ago, a cancer survivor was an individual who had lived five or more years beyond diagnosis. and that was commonly, you know, patients would talk about making it to that five-year mark

and consider themselves a cancer survivor when they reached that mark, but really this definition has changed and the national coalition for cancer survivorship, as well as, nci and cdc really consider a survivor from the time

of diagnosis and for the balance of that individual's life. survivorship also includes family, friends, and caregivers, and the thinking behind doing is that when a person is diagnosed with cancer, everyone around them is affected, so they too become

cancer survivors and part of that group. for many patients, cancer survivorship really begins when they stop their active treatment. they shift their focus from the sick role, to the well role,

and this can be a really difficult time for patients. they go from being seen by healthcare providers every three weeks, they go from doing something to keep themselves cancer-free, getting chemotherapy, getting radiation,

getting targeted therapy, to stopping active treatment. and it can be a very unsettling time, especially, the period of time from when they first stop their to that first follow-up visit that they have with their oncology team three

or four months later. they're coping during that time with the sequelae of treatment. they may have late effects. these are toxicities that are absent or not clinically apparent during their treatment, but that appear months to,

in some cases, years after the completion an example of a late effect is the cardiotoxicity that we see that have received doxorubicin. they may be struggling with long-term effects and these are complications or side effects

that began during treatment, but that persist beyond the end examples of that are the neuropathies that patients may have who were treated with platinum-containing chemotherapeutic agents or the lymphedema that may have

in an extremity as a result or they may have bowel or bladder dysfunction. they also are dealing in some instances, with an increased risk for a secondary malignancy and that is a treatment related malignancy.

young women that were treated with mantle radiation for hodgkin's disease are at an increased risk for the development of breast cancer. or they may have a risk of developing a second primary like patients with lung cancer,

are at an increased risk of developing a second lung primary. so survivors really do have a lot of challenges and with so many cancer survivors and with all of these unmet needs, survivorship has become more

of a focus for policy-makers, for advocacy organizations, for government agencies, and most importantly, for healthcare providers. i think we're suddenly finally getting it as physicians, nurses, social workers, that, you know, just

because someone's finished active treatment doesn't mean that all is well, so to speak. i want to call your attention to the report that's in this center , that's the institute of medicine's report, from cancer patient

to cancer survivor, lost in transition. and this report puts forward 10 specific recommendations which, i don't have time to go into today. i'm just going to talk a little bit about one of those recommendations.

and that is that patients who are completing primary treatment should, at the end of their treatment, be provided with a comprehensive summary of the care that they received, the treatment that they received,

and a follow-up plan. and this is increasingly being referred to as the survivorship care plan. and the survivorship care plan should include things like the type of cancer the patient was diagnosed with,

what specific treatment they received, what the potential consequences of that treatment is, is there those late or long-term effects, information about the timing and the content of recommended follow-ups,

recommendations regarding preventive health practices and how to maintain health and well-being. there also should be information on legal protections regarding employment and insurance, and the patient should also be made aware of,

the psychosocial services that are available to him or her. and lots of organizations have put together survivorship care plans and what you have on the screen in front of you is the one that was developed

by [inaudible] and this is also on the next screen. and what i want to call your attention to here, is the grayed-in area which is really follow-up care, when it should happen, how often, and who is the provider that's assuming

responsibility for that care. so really we're shifting our attention, beginning to focus more on the needs of survivors and are really trying to put in place survivorship care plans that are given to patients so they know exactly what they

need to do, once they're finished their here are some nci resources for survivorship. it's -- primarily they're facing -- i think of it as the facing-forward series. there's is a booklet for patients.

there's a booklet for caregivers or partners and the booklet all the way on the right is about how to make a difference in cancer care. okay. the last two slides that i have just show you how to order some

of these fabulous nci resources. this is the home page and if you type in the search box, radiation therapy, it will bring you to a page where some of the resources are listed, or if you click on nci publications, that,

in turn, will bring you to this page which is our pub's locator and if you know the title of the pub, you can type it in and search for it that way or you see that you can look for pubs in a variety of different ways, by audience,

by topic, by cancer. so with that, let me stop and i think i unfortunately didn't leave a whole lot of time for questions. i'm so sorry, but let's see if we can maybe at least get to one or two. thanks, annette.

we are running a little long on time so we will try to get to a couple of questions here, today. so as a reminder, folks. please press star one to be placed in queue to ask your question or if you would prefer,

you can also submit your questions. you can [inaudible] q and a feature at the top of the screen and we already have one question submitted via the q and a, so i'll turn things over to ms. linda parreco.

>> linda parreco: hi. thanks, candace. great job, annette. so we've got a question that just came in from natalie, asking if there's a way to decrease the side effects of radiation therapy such as are there creams

for the sunburn? so one of the things about that is probably focused on prevention. the radiation therapy side effects to the skin are obviously dependent on the part of the body that's radiated, but there's a lot of --

as nurses, a lot of self-care instruction that we give to patients so that they know how to, like, really take good care of their skin, such as not leaving the skin area moist, keeping it dry, not wearing tight waistbands

or tight clothing around the affected areas of the skin to be able to monitor the skin, and it's watched really closely by the treatment team. and so the skin kind of goes through a continuum of maybe a little bit of redness

and in some severe cases, if there is dry or moist desquamation of the skin, then certainly things -- steps are taken to treat the pain and manage any risk of infection.

the only thing i would add to that is that in my experience, radiation practices have their favorites, if you will, in terms of the preparations that they like to use with patients. and so the best advice

that i would give is to talk with the nurse in the radiation therapy department or the radiation therapist for what they might recommend. >> linda parreco: great. a second question. would you remind reviewing the

difference between local and systemic treatment once again. >> annette galassi: sure. so local therapy is that therapy that is confined to a specific area of the body. so local therapy is surgery because, it will deal only

with the removal of the colon tumor or the prostate and the prostate tumor. radiation therapy is -- at least external beam and brachytherapy are also local therapy because, the effects

of that treatment will only be on the area that the external beam radiation therapy is directed toward or where the brachytherapy is placed. systemic therapy is therapy that travels throughout the body and affects tissue throughout

the body. so chemotherapy, which is either administered orally or intravenously, travels systemically. hormonal therapy, same thing, travels systemically so is targeted therapy. >> candace maynard:

and unfortunately, i think that's all we have time for today. thank you all for your participation in our seminar today. your feedback is very important to us and we encourage you to complete the public comment.

the feedback from these pilot sessions will determine whether nci moves forward offering additional sessions of cancer classroom. the link to the public comment form will be emailed to you following our call this afternoon.

we hope you will join us again on june 28th for the third session in our four-seminar pilot from 2:00 to 3:30 eastern time as we present clinical trials 101. thank you all so much for joining us

and have a great afternoon. >> operator: thank you. this completes today's conference. you may disconnect at this time.