Imaging studies – These are commonly used for the evaluation of patients with suspected resectable malignant mesothelioma. Potential options available include CT, MRI, PET, and integrated PET/CT.

Chest CT – This is useful in identifying invasion of the ribs, chest wall and mediastinal structures. Potential indicators of tumor invasion include gross extension into mediastinal fat, loss of normal fat planes, and tumor which surrounds more than 50% of mediastinal structures. However, it has limited ability to accurately detect the involvement of intrathoracic lymph nodes.

MR imaging – For specific patients with suspected resectable disease, some physicians recommend Magnetic Resonance (MR) imaging in order to further examine the local extent of disease. In particular, coronal MRI may help identify the spread of pleural mesothelioma via the diaphragm into the peritoneal cavity.

PET scan – PET scans that make use of 18-fluorodeoxyglucose (FDG) have been helpful in detecting extrathoracic disease. However, in cases where only PET was used, a number of false negatives and false positives were reported during evaluation of mediastinal lymph nodes.

Integrated PET-CT – This type of imaging technique has proved most reliable for initial assessment of the patient. Below are three single institutional series that demonstrate the results obtained using the above technique:

• In the first series, 42 successive patients without any signs of T4 or M1 disease (based on CT) were evaluated using PET-CT. 12 patients (29%) were reclassified as terminal cases, based on the existence of a T4 lesion or distant metastasis (29% and 14% respectively).
• In the second series, 54 patients with suspected resectable mesothelioma (stage II/III) were evaluated using PET-CT. Surgical procedures were used to establish the imaging findings among 52 patients whereas two patients who had distant metastases were followed. It was noted that PET-CT was considerably more accurate than MRI, CT or PET alone for both stage II and stage III disease.
• In the third series, a comparison between PET-CT and CT in 35 patients was carried out. Based on the PET-CT findings, surgical resection was not indicated in 14 of the 35 cases (40%). This was usually due to the increase in the staging of the primary tumor.

Surgical staging – Extended surgical staging is recommended in cases where extrapleural pneumonectomy (EPP) is still being considered an option after imaging studies. In a series of 118 successive patients, surgical staging involved laparoscopy with peritoneal lavage in order to detect subdiaphragmatic involvement. This was followed by mediastinoscopy. This procedure helped avoid inappropriate interventions in 16 patients (14%).

Other studies – There are many other types of studies that can provide clinically useful ancillary information.

• Mediastinoscopy has shown to be increasingly effective in mesothelioma diagnosis and staging. This is based on recent studies that have shown considerable negative prognostic effects of mediastinal nodal invasion.
• Usually, pulmonary function tests have shown a restrictive pattern, resulting from chest wall involvement and/or encasement of the lung.

Medicines: Generally, social workers and psychologists work with psychiatrists who are able to prescribe medicines in order to help control your distress. At times, a drug is required to manage distress resulting from cancer, or distress caused by a specific medicine used in cancer treatment or another serious symptom. For instance, steroids such as Decadron® and prednisone can lead to mood swings. At higher doses, opioid pain medicines such as Dilaudid®, morphine, or fentanyl can induce confused thinking. Specific medicines may be required to control these symptoms.

Medicines used to treat depression (anti-depressants) or those that are used to treat anxiety (anti-anxiety medicines) can be administered to control distress and manage symptoms like poor appetite and sleep. Certain patients are afraid to take these medicines thinking that – “I might get addicted”, or “I will become a zombie”. Often, these concerns are exaggerated, quite similar to the unreasonable fear of taking narcotics to reduce cancer pain. There are many people who also fear that visiting a psychiatrist would imply that they are “weak” or “crazy”. However, similar to other health professionals, psychiatrists too are usually able to reduce severe distress levels by providing effective counseling and helping select the best medicines.

Pastoral services

During a crisis, (for instance when you or one of your family members has been diagnosed with cancer), many individuals prefer to discuss issues with a person belonging to their religious or spiritual group. Nowadays, many clergy have received proper training in pastoral counseling for cancer patients. They are usually available to the cancer care team and they usually see patients who may not be having their own clergy or religious counselor.

There is a great deal of significance attached to pastoral services because knowing that you have cancer can result in a crisis of belief or faith. Some people may start questioning their life’s purpose or wonder why God chose them to be cancer victims. Other individuals may treat the cancer diagnosis as a punishment from God or an indication that God has left them. Cancer patients can rely on their spiritual and religious resources to deal with their illness and find answers to these questions.

Clergy can help you deal with concerns such as:

• Grief
• Concerns related to death and the afterlife
• Internal conflict or dented belief systems
• Loss of faith
• Concerns related to the meaning or purpose of life
• Concerns related to the relationship with a holy being or God
• Guilt
• Hopelessness
• Isolation from the religious community
• Conflict between existing beliefs and recommended treatment
• Need for specific types of rituals

Special issues

Specific situations require special skills, for instance grief counseling and sexual counseling.

For grief counseling, you will find the Association for Death Education and Counseling quite useful. They have plenty of resources for individuals who need help or for those who may want to provide support to another person trying to cope with a loss.

If you need the services of a trained professional who specializes in sexual counseling and sex therapy, you can get help from the American Association of Sex Educators, Counselors, and Therapists.

How to choose the right counselor

In case you wish to get help from a counselor, it makes sense to find one who may have proper training and experience in providing care to cancer patients. Your cancer care team can be your best resource for seeking referrals to providers in your locality. The Psychosocial Oncology Society (APOS) is another good resource. Within 2 business days, they will help you get in touch with someone through their toll-free service at 1-866-276-7443. Using their services, you will be able to find a trained professional in your local area who can provide counseling to cancer patients. You need to make a call and ask for other professionals in case you don’t feel safe talking to or are not comfortable with the first one.

Previous post on this topic.

Nausea and Vomiting: Their Relationship with Brain Signals

What causes nausea and vomiting? Directly or indirectly, the brain controls all bodily functions and the same applies to stomach upset and vomiting. The act of vomiting is controlled by a specific region within the brain, generally referred to as the vomiting center. This site lies on the floor of the fourth ventricle, a location within the brain called the area postrema. This neurological center comprises of an array of receptor cells that can result in nausea and vomiting when stimulated. Also called a circumventricular organ, the area postrema is located outside the blood brain barrier. This implies that it can receive stimulation from blood-borne cytotoxic agents among other things. Along with stimulation received from chemotherapies, the area postrema can also lead to side-effects (induce vomiting) due to signals received from other anatomical sites such as:

• The cerebral chemoreceptive trigger zone (CTZ) which can be stimulated by drugs, chemicals, or foreign matter present in the bloodstream
• Organs in the digestive tract and nerves that respond to disease or chemotherapeutic discomfort
• Limbic system receptor sites and cerebral cortex that are stimulated by pain, emotional discomfort, odors, sight and taste sensations
• Internal ear receptors that react to motion

Stimulations and reactions associated with the vomiting center occur when receptor cells come in contact with specific chemical compositions called neurotransmitters. These neurotransmitters travel to the area postrema carrying several different instructions that can induce varied types of nausea and vomiting symptoms such as:

• Breakthrough vomiting – This refers to chronic nausea and vomiting that prevails even after antiemetic (anti-nausea) drugs and other therapies have been administered
• Acute nausea and vomiting – This relates to stomach discomfort and vomiting that occurs within a few hours after chemotherapy is administered
• Delayed nausea and vomiting – These side-effects take 24 hours or more to manifest after chemotherapy is administered
• Anticipatory vomiting – This refers to a general behavior noticed among some patients who experience nausea and vomiting just prior to the start of the chemotherapy session

At certain places, the social worker may be the only resource, who may be handling all psychosocial, psychological and practical problems. Services like these are normally included as a part of your total care. Information about community resources is also available with social workers. That way they can refer you to other types of local help resources, apart from providing counseling.

Practical problems: These types of problems can vary from everyday requirements, for instance food and clothing, to professional requirements, for example job issues. Here are a few examples of the most common practical problems that you or your family members may face, and which may require you to get help from a social worker.

• Concerns related to the illness, for instance, how to reach the treatment facility everyday, how to arrange for parking costs, and which place to stay for overnight hospital visits that happen at out-of-town locations.

• Concerns about finance

• Concerns about the job

• School-related concerns

• Food costs and how to prepare

• Help with everyday activities

• Language or cultural differences (when your culture or language may not be the same as that of people around you)

• Arranging help for family members and caregivers

To deal with problems that may only be leading to mild distress, the social worker can provide patient and family education, initiate support group sessions, and make available resource lists. In case the distress is severe due to practical problems, patient and family counseling may be provided by the social worker. Other services provided by a social worker can include referring people to community resources, teaching effective approaches to problem-solving, helping you get the required care, and initiating education and support group sessions.

Mental health

Generally, mental health services deal with the evaluation and treatment of your distress in the moderate to severe range (4 or more when evaluated using the distress scale). This type of distress can be due to emotional or psychiatric problems that the individual may have had faced before the diagnosis of cancer. Certain problems that can make coping a lot more difficult include the following:

• Severe depression

• Dementia

• Panic attacks

• Anxiety

• Substance abuse

• Mood disorders

• Adjustment disorders

• Personality disorders

All the above may worsen due to the distress resulting from cancer diagnosis.

Usually, mental health services are offered by psychiatric nurses, psychiatrists, psychologists, and psychiatric social workers. Often, social workers and oncology nurses are also highly skilled and experienced in these specific areas. Normally, one of these members will be a part of your cancer care team. To help you cope, mental health professional rely on a wide variety of counseling and therapy approaches. They usually begin by helping you identify ways or approaches that may have proved effective for you earlier. These professionals will respect your individual coping style and attempt to strengthen it even more. They can make it possible for you to understand how past experiences or problems might be making it difficult for you to cope with the cancer. They can also teach you specific techniques such as meditation and relaxation to help you cope with your distress.

• Had experienced major mental health problems such as depression in the past
• Have other serious medical complications apart from cancer
• Face communication problems (for instance hearing problems or a different language)
• Are facing some kind of family or social problems
• Are younger
• Are living alone
• Have young children to take care of at home
• Have had experienced very high levels of stress (even before the diagnosis of cancer)
• Have had a history of alcohol or drug abuse

If any of the above applies to you, there is an increased likelihood that you may require help from other people – referrals to the right people can be provided to you by the cancer care team.

You along with your cancer care team members may also realize that on certain occasions during the course of the disease and treatment, you face an increased risk of severe distress. Cancer has often been described as something similar to “being on a roller coaster”. Usually these occur at specific points of change during the course of the disease and its treatment:

• Having a new symptom that looks suspicious
• Changing treatment
• Going home after being discharged from the hospital
• Completing treatment
• Going for follow-up-visits to your cancer doctor
• The cancer recurs (comes back)
• Treatment failure
• The cancer worsens or reaches advanced stage
• Advancing towards the end of life
• Moving onto hospice care

In case you experience moderate to severe distress levels during these periods, you may require additional help.

Counseling services that you may require

The type of problems you may be facing and your distress levels will make it easier for you to decide the type of services that may be most useful for you.

Social work

In majority of places, the first support person you may come across is likely to be the social worker who acts as the “first responder”. When your cancer care team needs to refer you to another expert for your distress, your situation will be assessed by a social worker to check whether your distress is due to psychosocial or practical problems.

Psychosocial problems: The term psychosocial has been derived from the combination of mental or psychological health and social circumstances or aspects. Given below are a few examples of psychosocial problems:

• Having problems with adjusting to illness
• Facing family and social isolation
• Conflict in family
• Having problems with treatment decisions
• Worried about the quality of life
• Trouble coping with changes in care
• Trouble making decisions about future medical care (advance directives)
• Experiencing neglect or abuse at home
• Facing coping issues or having trouble communicating
• Changes in the thought process and your feelings about your body and perception of your sexual self
• Grief problems
• Issues related to end of life
• Cultural problems
• Caregiver related issues or the need to get ready for caregiving and initiate caregiver support

Social workers help patients and their families facing psychological problems by:

• Teaching patients and their patients
• Providing support and education group sessions to patients and their families
• Providing you with resource lists and locating community resources where you may find the required help
• Providing counseling to patients and their families about grief and relationships

These will be most effective when the level of distress is reasonably low (4 or less).

In case the problems are of a more serious nature, patient and family counseling or psychotherapy can be initiated. Patients and/or their family members can also be referred to psychosocial or psychiatric therapy or pastoral counseling, and specific problems may require grief or sexual counseling. Community resources may also be offered by the social worker to help families facing serious issues, for instance organizations that provide help to women who may have faced abuse at home.

Information related to risk enables oncologists (doctors who treat individuals diagnosed with cancer) and researchers to chalk out treatment plans and improve the health of a number of individuals. For instance, the knowledge that individuals who smoke face an increased risk of lung cancer as compared to individuals who do not smoke, was the underlying factor that prompted a worldwide campaign to reduce the total number of smokers.

Risk factors

A risk factor can be anything that increases an individual’s probability of developing cancer. Certain risk factors are controllable, for instance smoking, whereas others are not, for example, age and family history. While it is true that risk factors influence the onset of cancer, most of these do not directly cause cancer. There have been instances where certain individuals with multiple risk factors had not developed cancer, and those without any known risk factors were diagnosed with cancer. Nonetheless, understanding your specific risk factors and communicating the same to your doctor can enable you to make more informed healthcare and lifestyle choices.

It is important to understand your specific risk of cancer. Individuals who may have close relatives either diagnosed with cancer or may have died due to cancer (especially at a relatively younger age), face an increased risk of cancer. For instance, if the mother or sister of a woman had cancer, the risk for breast cancer will be twice as much, as compared to a similar woman who may not have the same type of family history. Screening tests can be beneficial for people with a history of breast cancer, especially when done at a relatively younger age and more frequently. Individuals belonging to families with a known genetic syndrome can opt for genetic testing. Your genetic counselor or doctor can help you in assessing your specific risks of developing cancer.

Risk information can also be used to assist people diagnosed with cancer to make decisions about their treatment. This would involve comparing the risks and benefits of available treatment options, for instance the effectiveness of treatment, the known side effects, and it’s affect on quality of life.

Why inform your children about the cancer?

When families decide not to share news of a cancer diagnosis, it is possible that children may still catch on the underlying stress and cancer in the family. As such, they may suspect that something important is not being revealed to them. To get information, children may try to listen to conversations happening between family members. Or it is possible that they may only hear bits and pieces, or specific things that were not meant to hear. Even when they may not be able to understand what exactly is being discussed, they may just feel that something has gone wrong.

Most children usually perceive the world as it relates to them. It is very common for children to start believing that it was something they said or did has resulted in the cancer. Always remember this and make sure you talk about it when your child gets to know about cancer diagnosis in a loved one.

In most cases, cancer is not something that children have experienced or are able to understand. There is a tendency among children to make broad generalizations and understand only concrete information. Children may not understand that there are several different kinds of cancer, that every individual’s cancer is different, and that development of cancer does not imply that the person will die soon. Children may get ideas and information from other children and possibly from what they see in their everyday life, including things that they see on television. When the right information is not available, children may use their imagination to fill the gaps. In many cases, what children imagine is actually much worse than reality.

How to inform your children about cancer diagnosis

When diagnosed with cancer, people usually find it difficult to decide about what to tell their children. How much the child needs to know and how much they can handle depends on their age and maturity level. You need to pass on information to your child in small amounts at a time, and in simple words that they can understand easily. After this, give them enough time to accept the facts and encourage them to ask questions. See if they are unable to understand certain words or are scared of them. You need to patiently listen to their concerns. Encourage them to openly express their feelings and provide them the reassurance of your love. It is usually easier for children to express their feelings through specific activities, for instance painting or puppets. Older children may want to draw pictures or write poetry.

What exactly to tell about cancer

Adults can inform children about the developments in just a couple of sentences. “I was told by my doctor that I am sick with development of cancer. Doctors will try their best to help me recover. I will have to visit the doctor frequently and receive special medication, so it may not be possible for me to spend much time with you. There may be times when I might feel very unwell and am unable to do certain things such as playing with you, but I will still be here. You need to understand that I love you so much.” If the individual is feeling uncomfortable about informing the child about the cancer diagnosis, a close friend or relative can be asked to convey the news. This usually depends on the relationship that the cancer patient shares with the child (for instance parent, aunt or grandparent).

Live life normally

There are many reasons as to why children might face problems when coping up with cancer diagnosis in a parent or another member of the family. The patient may be receiving treatment at a place far away from home, or it is also possible that they may be recovering at home and feel uncomfortable or look awkward. Children may also be told to help out more or display their best behavior, especially when individuals other than their parents may be involved in providing care. It is possible that children may question or even dislike any loss of attention.

If family members or friends offer to help, asking them to take your children to school or for some other activities will help a great deal, especially when you are unable to do so. Doing so will help maintain normalcy in the day-to-day routines of your child.

The focus of younger children may be on death. Older children with a growing sense of being independent need to cope up with the changes occurring in their life, and also prepare themselves for potential long-term separation or may be even death of their loved one.

While it is essential to try and maintain normalcy in the daily routines and lifestyle of children, they also need to be given the chance to function as part a family, one that is coping up with cancer. Certain questions may be put forth by children such as the site of administering treatment and potential changes that they may notice in the cancer patient.

Many children try to behave like adults in an attempt to make life easier for their parents. A support group meant for children may provide them the right platform to express their frustrations. Good resources that can provide you information about support groups functioning in your area include nurses, hospital social workers, psychologists, school counselors and clergy members.

You may feel lonely or you may start living alone. It may appear to you that there is not much to live for now. If you cannot find support through your family members and friends, you need to find others who can. In your community, there may be other who may need your companionship, just as you may need theirs. The collective support of other people with cancer may also act as a source of comfort. For resources in your community, you need to talk to your health care team, a clergy member, or your local American Cancer Society office.

Types of support groups and programs

There are many different types of support programs and these include both individual and group counseling and support groups. Some of these groups are formal and their focus is on increasing awareness about cancer and coping with feelings. There are also those that are informal and social. Certain groups comprise of only cancer patients or only caregivers, whereas other may allow family members, spouses, or friends as members. Other types of support groups focus on specific forms of cancer and its stages. As mentioned earlier, cancer support groups meant for children are also functional in certain areas. Groups may meet for a specific number of weeks it can be an ongoing program. Certain programs have limited or closed memberships whereas others allow new, drop-in members.

People such as trained facilitators, a member of the group, or health professionals such as a nurse, social worker or other licensed professional can lead the group. A group leader should have received specific training before they can take charge of any of these support groups.

People who are not in a position to attend appointments and meetings can seek counseling over the telephone which is offered by specific organizations. Certain individuals may prefer online support groups because they offer more privacy. You may find it comforting when you chat with people facing the same situations as you are. However, remember that message boards and chat rooms are considered the best medium to get information about cancer, especially when you are not being monitored by experts or trained professionals.

Irrespective of the specific type of group, all members should be able to feel comfortable in the group and get along well with the facilitator. In case you have certain uncertainties or fears before joining a group, you need to talk about these to the facilitator of the group.

Apart from support programs, there may be other means to get support in your community. These include:

• Social services, for instance financial aid and counseling
• Home health nursing services
• Nutrition services which offer meals or provide you services of a registered dietitian
• Rehabilitation services offered by physical or occupational therapists
• Spiritual services offered by chaplains or religious practitioners in your community

Support of any type allows you to express your feelings and acquire specific skills to deal with the changes occurring in your life. Some studies have shown that individuals who seek help through support groups experience better sleep and appetite and an improvement in the quality of life.

Self-help groups

Self-help groups are usually operated by non-professionals who have faced the same types of problems or situations. Members of these groups might be able to understand your problems in a better manner and offer helpful tips and advice related to your treatment. For instance, they may tell you about an effective home remedy for nausea, or inform you about shops that offer wigs and turbans at affordable rates. When family members are not present, people with cancer are free to express their feelings. Family members may also gain by sharing their fears, anxieties, insecurities and frustrations with other families facing similar situations.

Through self-help groups, individuals recovering or those who have recovered from cancer can get a chance to serve other cancer patients. With some specific training, many individuals have felt that helping others makes them feel comfortable and improves their self-image. Overtime, these people may take up the role of group counselors or facilitators.

It is important to decide when exactly to join a support group. For some individuals, it is difficult to take part in a support group when they have been newly diagnosed with cancer. The experiences that patient may share, after months or may be even years of treatment, can be upsetting and overwhelming. In case you are not satisfied with the experiences in a specific group, you can consider rejoining at a later date or try another group.

Religion

For some individuals, religion can act as a source of strength. Some individuals find new faith after being diagnosed with cancer. Other people find that their cancer diagnosis helps strengthen their existing faith or that their faith provides them newfound hope and strength. People who may not have strong religious beliefs earlier may not feel inclined to turn to religion during this time. You can seek spiritual support through a rabbi, a minister, a trained pastoral counselor, or any other leader of your faith. Some clergy members are specially trained to provide guidance to cancer patients and their families. Certain hospitals also offer chaplain services.

Treatment for cancer focuses not just on the cancer, but also on the care required by the patient and his/her family. A mental health professional may have already been included in the cancer care team. If not, you need to ask your doctor or nurse about other available resources that may help you and your family members deal with cancer.

Cancer patients often claim that communication gaps between their family members create problems. Changes in roles and responsibilities can lead to anxiety and resentment. Some members of the family may not be comfortable discussing their experiences openly. Other members of the family may tend to avoid the individual with cancer because they may believe that they don’t have anything to offer, are not sure how to respond, or feel that there is not much they can do to improve the situation. All these factors can create distances between family members at a time when they may be required to work together as a team. A lot of families may require help with this. By getting help through family counseling, members of the household can learn to cope with changes that happen within the family and express their feelings in a comfortable manner.

To relieve stress, family members and friends can take part in specific outdoor activities. Outside resources, for instance support groups or counseling, can provide a means to express your frustrations that you may be experiencing within the family.

Remember that not all cancer patients may want to share their feelings. Some people may want to use other means to express their feelings, for example, through art, music, yoga or writing in a journal. Others may choose to keep their emotions private. People diagnosed with cancer may just expect you to help them maintain their usual routine. Just be yourself and make sure you continue to act in the same manner as you would have in case they weren’t diagnosed with cancer.

Changes in the family

A cancer diagnosis changes a family forever. Thinking about specific things such as what’s for dinner or what are the plans for the weekend suddenly appear less important. Priorities are tested and replaced and there is a tendency to question family and personal values. Unresolved arguments and feelings may come back while a family is trying to deal with cancer. Families first need to re-examine old, unsettled feelings before they begin their battle against cancer, working together as a family unit.

A family can also experience role changes due to cancer. The head of the family is likely to become more dependent on other members of the household. Other individuals may have to work outside the home or reschedule their work hours. When members of the family acquire new roles, their interactions within the family can change significantly. Some members of the family may feel overwhelmed by the new responsibilities.

Parents may expect their children to provide support. In case the children are mature enough, other household members may expect them to shoulder more responsibilities within the family. Often, these requests are made when children may themselves require support. Younger children may demonstrate regressive behavior due to the stress faced by the family. Behavioral changes may be their own way of coping with cancer and the changes it has brought about in the family. Adolescents, who are usually rebellious and spend more of their time with friends, are rather more likely to stick to their family members for support.

As a family member of friend who is helping a loved one with cancer, you too have your own personal needs. If you take care of yourself, you will be in a better position to provide care to others. The patient is likely to benefit when your own personal needs are met. Overdoing is quite unlike doing. Realize your limits and take ample rest when you feel the need for it. This is applicable to both patients and caregivers.

Some families tend to consider the person with cancer as an invalid, even when he/she may be fully capable of taking care of themselves. In certain cases, people with cancer may not require your help with things such as bathing and dressing. If possible, you need to respect these wishes.

While the cancer patient may refuse to get help from outside, family members and friends need to realize their limitations and seek help whenever needed. Home health aides, certified nursing assistants and other resources can provide the required care to the patient. Churches in the local area can provide help with general housekeeping, cooking, transportation and shopping. Professional services can also prove helpful, although normally you have to pay a fee, which is unlikely to be covered by your health insurance.