When dealing with cancer, your immediate concern is to treat the cancer you have. Nobody wants to have to also focus on the risk of developing new and different tumors caused by the cancer treatments – or “secondary malignancies” as they are often called. However, it is now something doctors speak about with patients before treatment begins.
Secondary cancers can occur several years or decades after treatment is completed and are sometimes a consequence or side effect of the original cancer treatment. Radiation, chemotherapy, and targeted therapy can all cause secondary cancers. For radiation, the risk increases when normal, healthy tissues are exposed to radiation during treatment.
“I usually explain secondary cancers as new and different tumors caused by treatment. It’s not their original cancer coming back,” says Dr. Stephanie Schaub, who treats childhood and adult sarcomas at Fred Hutchinson Cancer Center – Proton Therapy. “After radiation therapy to certain parts of the body, I let my patients know that I may recommend adjusted screening schedules to make sure any secondary cancers are caught early.”
“If the secondary cancer is within the original radiation field, it is generally assumed it is due to the radiation exposure,” adds Dr. Ralph P. Ermoian, radiation oncologist and childhood cancer specialist at the proton therapy facility.
An article in the March 2022 issue of Cure magazine featuring Dr. Schaub notes, “Cancer researchers are continuously working to develop newer treatments with fewer side effects while also trying to understand their association with risks for developing secondary cancers.” It’s an excellent in-depth look at secondary cancers, and recommended reading for anyone undergoing treatment for cancer.
Among other treatments, the article highlights proton therapy, which may decrease the risk of treatment-related secondary cancers from radiation by allowing oncologists to treat the tumors with less radiation to surrounding healthy tissues. According to a 2009 study by M.D. Anderson Cancer Center, proton therapy reduces the risk of secondary cancers by 26–39% compared with standard (X-ray) radiation therapy.
“When it comes to patients needing external radiation, protons are the most precise in targeting the tumor, reducing exposure to radiation to healthy parts of the body,” says Dr. Ramesh Rengan, Professor and Chair of the Radiation Oncology department at UW Medicine. “Therefore, protons are the least likely among types of external radiation to put the patient at risk for secondary malignancies.”
Secondary cancers within the original radiation field most commonly appear 10 years or more after treatment, so childhood cancer patients are most at risk for developing these tumors, as they generally have decades of life ahead of them. In addition, their growing bodies are more sensitive to radiation. Because it can decrease this risk, proton therapy is the preferred form of radiation for many childhood cancer patients.
“Proton therapy for pediatric tumors not only potentially reduces the risk of developing secondary cancers from radiotherapy treatment, but due to its precision can reduce the risk of other long-term late side effects,” says Dr. Schaub. “This includes allowing us to potentially reduce critical radiation dose to the brain to minimize the impact on cognitive effects, reduce radiation dose to the pelvic organs which may contribute to fertility preservation, and reduce dose to the heart which can minimize the risk of developing heart disease.”
As with all cancer treatments, it is important that patients know all the associated risks, so they can make an informed decision about their treatment plans.
The holidays can be challenging for cancer patients. You may not feel like you used to, or you may be unable to gather as you did in the past due to infection risk. But the holidays can also be a healthy dose of normalcy, connection, and tradition. Facing a life-altering illness can help patients cherish time with loved ones, especially by making holiday memories.
Every part of life can potentially be affected by a cancer diagnosis, from physical changes to spiritual distress. “At Fred Hutchinson Cancer Center, we have a Supportive Care division that is comprised of social workers, patient navigators, spiritual health clinicians, psychiatry providers, palliative care teams, and integrative medicine teams,” says Jourdan Cruz, MSc, MSW, LICSW, social worker manager for Fred Hutch. “Each of these teams are trained to address one or more of the setbacks and obstacles patients may face.”
Although not every patient experiences all challenges, here are the primary ones of concern, along with ways to alleviate some of the stress they create:
The physical impact of cancer varies with each patient, but common concerns are fatigue, changes in appetite, sleep, and stamina.
“Talk to your medical team about options to address any physical symptoms which you find difficult to live with, or adapt to,” says Cruz. “For the holidays, you may need to adjust your social schedule to accommodate increased rest periods, or infection prevention measures. Work with your medical team to discuss what is feasible for you and your loved ones.”
During the holidays, side effects related to eating can be especially impactful. Treatments for cancer might impact your desire or ability to eat. These might include, nausea, taste changes, difficulty swallowing, or bowel changes. Navigating the holidays, when food is an important part of celebrations, can be difficult for patients undergoing cancer treatment. Our proton therapy dietician, Laura Buono, RD, CSO, CD, CNSC, offers some tips for holiday eating. “Focus on nutritious foods when you can to help your body heal during treatment. Of course, it’s still okay to have some sweets and treats. Try to find creative ways to enjoy meals despite the side effects for cancer treatment. For example, ginger is known to ease nausea. Why not try some gingerbread cookies with real ginger? For trouble swallowing, foods like mashed potatoes, yams, stuffing, and perhaps a pudding or pumpkin pie for dessert might ease swallowing pain or difficulty.” If you have altered taste from your treatment, try flavors that are tart, tangy, or sour. For example, squeeze lemon on food, add a splash of vinegar, or sprinkle on some parmesan cheese. If you’d like to consult with Buono, please reach out to our patient navigator/concierge team at firstname.lastname@example.org. Consults are free.
Patients may face their mortality in a way they have not previously, or deal with feelings of depression and anxiety. Sometimes patients feel like they are a burden to their family or friends.
“Please know that you are not alone if you are struggling with any sort of emotional distress around your diagnosis,” says Cruz. “We are here to support the whole you, not just your physical body. If you need us, reach out. At the proton therapy facility, our social worker is Elizabeth Darlington. You can reach her at email@example.com or (206) 306-2815.”
A first step to addressing any self-critical thoughts is to practice self-compassion. Cruz recommends this website to get you started. You can also join our Balancing Mind and Body with Breath meditation session this December 16 or January 20 at 3 PM. Email firstname.lastname@example.org to get connected.
Spiritual distress can manifest itself as doubt or anger in one’s belief system, feelings of unfairness, hopelessness, and feeling lost or abandoned.
“It is very common to have some type of spiritual or existential distress or struggle when coping with cancer or another serious diagnosis, even if you do not identify as spiritual,” says Stephen King, PhD, director of Chaplaincy at Fred Hutch. “Spiritual health clinicians are trained to talk with you about your struggles in a supportive and respectful way. Your health care team can help you connect with a Spiritual Health clinician, or you may want to talk with your own spiritual representative or therapist who has training in this area.”
Mental challenges can come from the disease itself, or from the treatment (for example chemo brain) and can leave you confused or overwhelmed.
If you find that you are having difficulty tracking appointments or treatments, or if you feel more confused than before you started treatment, talk to your medical team,” says Cruz. “There may be additional ways they can help, such as making sure you have multiple copies of your schedule, or providing written instructions that are clear to you, and anyone who may be helping you out at home.”
Social isolation, whether from infection risk or some other cause, can easily add to the stress a patient is feeling. Should you experience a decrease in support from your friends or family, ask your medical team to speak with a social worker. They may be able to help you process the changes, or work on communication strategies that may help reconnect with your support system. In addition, our psychologist, Ty Lostutter, PhD, recommends this article for tips on “surviving” the holidays, including acknowledging that feelings come and go, avoiding the holiday expectations trap, and remembering the positives in your life.
Uncertainties about finances is a major concern for the many patients. It is often not just the cost of treatment itself, but lost wages from time away from work. At Fred Hutch, a social worker or a patient navigator can help you locate and apply for financial support, whether in the form of governmental assistance or charitable grants. There may be options that you qualify for.
In the event you are facing some of these challenges, what are some effective ways to have a more enjoyable holiday season? “While struggles persist and you may not be able to experience all the happiness you are accustomed to, there may still be some ways to enjoy the season,” says King. “If gift giving is financially challenging, think of gifts that have minimal financial expense like handwritten notes of appreciation, or time together for particular experiences. If travel is challenging, financially or because of health, find ways to connect remotely, for example a shared meal or experience over a video call. If you feel guilty that you can’t provide as much as you’d like or even shame that you cannot be who you want to be during this time, try to practice forgiveness, self-compassion, acceptance of who you are as a person. Focus on being grounded, the beauty that you can see and/or experience, relationships, the meaning of the season, or something for which you can be grateful. May you experience some joy and beauty in the December holiday season, even in the face of ongoing struggles.”
Dr. Neil Panjwani will soon be treating patients at the Fred Hutchinson Cancer Center – Proton Therapy, focusing on patients with head and neck cancers. Dr. Panjwani was always fascinated with how the human body works and studied biomedical engineering at Duke University. He developed an interest in radiology while researching ways to automatically diagnose colon cancer on CT scans while at the National Institutes of Health. In medical school, he was drawn to radiation oncology because physicians develop strong relationships with patients as they work together to fight cancer and it employs innovative technologies which are continuously improving.
While training at Stanford University under Dr. Quynh Le and Dr. Beth Beadle – both leaders in radiation oncology – he developed an interest in head and neck cancers. “Head and neck cancer is the most complex disease site,” says Dr. Panjwani. “The area is small compared to other parts of the body and there are several nearby sensitive structures at risk of developing side effects. There is tremendous opportunity to improve outcomes and reduce toxicity.”
Though Dr. Panjwani hasn’t treated patients at the proton therapy facility yet, he’s excited about the opportunity. “When I first learned about proton therapy, I was very interested in its potential to spare radiation dose to those surrounding organs, as well as to reduce side effects, which can sometimes be severe for head and neck cancer patients. It’s incredible to be able to offer multiple radiation treatment options for Fred Hutch/UW Medicine patients, including photons, protons and neutron therapy.”
His research focuses on the applications of artificial intelligence and machine learning in radiation oncology, including using AI/ML to help select the optimal treatment for patients, automated organ and tumor image segmentation, automated treatment planning, and adaptive radiation techniques.
In his spare time, Dr. Panjwani and his wife, Gaurvika, like to spend time outdoors. He’s joined a competitive tennis league and wants to start playing pickleball. They also like to hike (they have visited 15 national parks to date) and enjoy the rich nature that is so abundant here compared to where Dr. Panjwani grew up in the Southern California High Desert. The couple feels lucky that many of their friends have also moved to Seattle and look forward to exploring all that Seattle has to offer.
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