WHAT IS KIDNEY DISEASE?

Kidney disease occurs when the nephrons inside your kidneys, which act as blood filters are damaged. This leads to the build up of waste and fluids inside the body.
Why are your kidneys so important?
Kidneys are the silent partner to good health! We can live quite well with only one kidney and indeed, some people live a healthy life even though born with one missing.
Our kidneys are amazing, they play a major role in maintaining your general health and wellbeing but are not usually thought of as essential to a healthy life. But while bones can break, muscles can waste away and the brain can sleep without risk to life, if both kidneys fail, as happens in end stage kidney failure, bone, muscle or brain can not carry on.
What can go wrong with your kidneys?
Kidney disease is called a silent disease as there are often no warning signs. More often kidney function worsens over a number of years.

This is good news because if kidney disease is found early, medication, dietary and lifestyle changes can increase the life of your kidneys and keep you feeling your best for as long as possible.

• You can lose up to 90 per cent of kidney function without realising it, by which time it is almost impossible to prevent further serious problems.
  
• People can live a near normal life with as little as 20 percent of their total kidney function.
  
• When symptoms do occur the initial signs may be general, such as feeling tired or generalised itching.
  
• As kidney disease progresses, the symptoms can include changes in the urine (reduced volume, discolouration, blood or pus), nausea and vomiting, and appetite loss.
  
• Other symptoms include swollen or numb hands and feet (because of water retention), weakness and lethargy, darkened skin and muscle cramps.  

Acute Kidney Failure is sometimes kidney failure which can happen quickly, caused for example by a sudden loss of large amounts of blood, infection, or an accident. A sudden drop in kidney function is often short lived but can occasionally lead to lasting kidney damage. 
Chronic Kidney Disease (CKD) is responsible for substantial burden of illness and premature mortality. If you lose over 1/3 of your kidney function for over 3 months, it is called Chronic Kidney Disease (CKD). Sometimes kidney disease leads to kidney failure, which requires dialysis or a kidney transplant to keep you alive. As kidney function decreases, waste begins to build-up in the blood.
How can I avoid kidney disease?
You can reduce your risk of kidney disease especially if you are at increased risk:

• become a non-smoker
• ensure your blood glucose is well controlled if you have diabetes
• control your blood pressure
• stay fit, exercise regularly and maintain a healthy weight by eating a healthy diet
• avoid high salt foods and reduce salt intake wherever you can
• drink water - instead of sugary drinks
• drink alcohol moderately (no more than 2 standard glasses a day for men -1 standard glass for women)

 WHAT ARE THE STAGES OF CHRONIC KIDNEY DISEASE?
Test results or clinical values can be grouped to show how well your kidneys are working. These groupings are only a guide and results may be outside these ranges. Kidney function may naturally fall as we age. Other factors can also lower kidney function normally.
Kidney function can be classified into stages, depending on your eGFR. Your doctor uses these stages as a guide for deciding which treatment is best for you. Treatment also depends on the cause of your kidney damage. Controlling diabetes and high blood pressure can help to slow or prevent further kidney damage. It also reduces the risk of other health problems, such as heart attacks and strokes.

Stage 1:  A normal GFR greater than or equal to 90 mL/min/1.73m²
Stage 2:  Slightly decreased GFR between 60‐89 mL/min/1.73m²

If your kidney function is at stage 1 or 2, you only have CKD if you have albuminuria, haematuria, a pathological abnormality or a structural abnormality.

Stage 3a:  Mild‐moderate decrease in GFR between 45‐59 mL/min/1.73m²
Stage 3b:  Moderate‐severe decrease in GFR between 30‐44 mL/min/1.73m²

Stage 4:  Severe decrease in GFR between 15-29 mL/min/1.73m²
Stage 5:  Kidney failure as GFR decreases to less than 15 mL/min/1.73m² or dialysis is started

Your eGFR and albuminuria results are combined to provide an overall picture of how well your kidneys are working. Your doctor uses this information to decide which treatment is best for you. Treatment also depends on the cause of your kidney damage. Controlling diabetes and high blood pressure can help to slow or prevent further kidney damage. It also reduces the risk of other health problems, such as heart attacks and strokes.

Image from Kidney Stories - for Indigenous Australians - graphics made available by NT Renal Services

COMMON KIDNEY RELATES TESTS AND PROCEDURES People with kidney disease undergo a large range of medical tests and procedures. Medical tests are an important part of making an action plan to meet your health care needs. They are needed to confirm a diagnosis, plan treatment or check progress. Some of the most commonly used tests for people with kidney disease are outlined here. Also see Kidney Glossary to find out meanings of terms used in tests.
Tests for kidney function and damage
Blood tests

• Estimated Glomerular Filtration Rate (eGFR): the best measure of your kidney function. It shows how well your kidneys are cleaning the blood. Your GFR is usually estimated (eGFR) from the results of the creatinine blood test. 

• eGFR is reported in millilitres per minute per 1.73m² (mL/min/1.73m²)
• A GFR of 100 mL/min/1.73m² is in the normal range so it is useful to say that 100 mL/min/1.73m² is about equal to ‘100% kidney function’ 
• A GFR of 50 mL/min/1.73m² could be called ‘50% kidney function’

• Creatinine: a waste product made by the muscles. It is usually removed from the blood by the kidneys and passes out in the urine. When the kidneys aren’t working well, creatinine stays in the blood. Creatinine varies with age, gender and body weight so is not an accurate way of measuring overall kidney function. When on dialysis creatinine levels are always high.
  
• Urea - a waste product, which is made as the body breaks down protein. High urea levels suggest decreased kidney function.

Urine tests

• Albumin Creatinine Ratio: used to measure the amount of albumin (a kind of protein) that leaks into your urine when your kidneys are damaged. A small or ‘micro’ amount of albumin in the urine is called microalbuminuria, and a larger ‘macro’ amount is called macroalbuminuria
  
• Urinalysis: an examination of a urine sample to detect medical conditions like kidney and liver disease, diabetes and urinary tract infections. This can be a visual examination for colour and clearness. For example, blood in the urine (haematuria) may make urine red or an infection can make it cloudy. A chemically treated strip or dipstick is used to test for pH, sugar (glucose), blood, bacteria or waste products. A urine sample can be sent to a laboratory for an examination under a microscope or to grow a culture if an infection is suspected.

Blood tests for diabetes

• Glucose: blood glucose monitoring is a measurement of glucose (sugar) in the blood. Values can vary depending on physical activity, meals and insulin administration. Your glucose level is raised in diabetes.
• Glycosylated haemoglobin (HbA1c): test that measures the amount of glycosylated haemoglobin in the blood. Glycosylated haemoglobin is a molecule in red blood cells that attaches to glucose (blood sugar). There are higher levels of glycosylated haemoglobin if you have more sugar in your blood.

Tests for heart health

• Blood pressure: the pressure of the blood against the walls of the arteries as the heart pumps the blood around your body. Blood pressure is recorded as two numbers, for example 140/90 mmHg. The larger number indicates the pressure in the arteries as the heart squeezes out blood during each beat. This is called the systolic blood pressure. The lower number indicates the pressure as the heart relaxes before the next beat. This is called the diastolic blood pressure.

Blood tests - Cholesterol

• Cholesterol: a naturally-occurring, waxy substance made by the body.  It is an essential building block of cell membranes, hormones and vitamin D. Too much cholesterol in the blood can cause clogging of the arteries and lead to heart disease.
• Low-density lipoprotein (LDL) cholesterol: known as the “bad” cholesterol. The higher the amount of LDL cholesterol, the higher the risk of heart disease.
• High-density lipoprotein (HDL) cholesterol: known as the “good” cholesterol. The higher the amount of HDL cholesterol, the lower the risk of heart disease.
• Triglycerides: the most common type of fat stored in your body. A high level of triglycerides in your blood can increase your risk of heart disease.

Blood tests for vitamin and mineral levels

• Potassium (K+): a mineral found in many foods.  If your kidneys are healthy, they remove extra potassium from the blood.  If your kidneys are damaged, the potassium level can rise and affect your heart.  A low or high potassium level can cause an irregular heartbeat.
• Sodium (salt, Na+): a substance which together with chloride makes up common salt. High levels of sodium may indicate dehydration.
• Calcium (Ca): needed for healthy bones and teeth. Most of the cells in the body need calcium to work properly. Raised calcium levels may cause headaches, nausea, sore eyes, aching teeth, itchy skin, mood changes and confusion.
• Phosphate (PO4): a mineral, which together with calcium keeps your bones strong and healthy.  Too much phosphate causes itching and pain in the joints, such as the knees, elbows and ankles. When the kidneys are not functioning properly, high levels of phosphate accumulate in the blood
• Vitamin D: a vitamin that is made in your skin after you have been in the sun. The kidneys change Vitamin D so that your body can use it.

Tests for anaemia

• Haemoglobin (Hb): the oxygen-carrying part of red blood cells that gives them their red colour and transports oxygen around the body.
• Haematocrit (Hct): a measure of the percentage of blood made up of red blood cells.
• Transferrin saturation (TSAT): indicates the proportion of the iron-transporting protein transferring and helps to determine if the body is transporting or binding iron in the right way.
• Ferritin: a protein that stores iron in your body.

Tests for hormones

• Parathyroid hormone (PTH): helps control calcium, phosphorus, and vitamin D levels within the blood and bone. Kidney failure can cause the parathyroid glands to produce too much PTH.

Imaging tests

• X‐rays: uses very short energy beams to produce an image of body parts such as bones and organs.
• Ultrasound: Examination of the kidneys, prostate or bladder using sound waves to outline the structure of organs.
• Computerised Tomography (CT) Scan or Magnetic Resonance Imaging (MRI): these tests use multiple small X-ray beams, or radio-frequency wavelengths and a strong magnetic field to provide clear and detailed pictures of internal organs and tissues. You may be asked to swallow a liquid containing a positive contrast material or ‘dye’, which allows the radiologist to see the kidneys more clearly.
• Kidney biopsy: a procedure where a needle is passed through your skin into the kidney and a small piece of kidney tissue is removed for examination under a microscope. Local anaesthetic is used and it is a relatively painless procedure.
• Fistulagram: used to check fistula function. Dye is injected into your fistula to allow its structure to show up on an x‐ray.
• Cystoscopy: this test uses a thin, flexible, tube-like telescope called a cystoscope to view the inside of the bladder and some parts of the kidney.
• Intravenous Pyelogram (IVP): series of x‐rays of the abdomen taken after dye has been injected into a vein in the arm. The dye is then viewed on the x-ray pictures as it passes through the kidneys

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Your Mind on Chemo

Mentioning chemobrain to a group of cancer survivors is the equivalent of yelling "FIRE" in a crowded theater.

             Yesterday it was impossible to miss the collective shouting
when the Radiological Society of North America (RSNA) announced the
results of a small study demonstrating the physiological process behind
the symptoms that plague so many of us.

             Now there is a scientific explanation behind that freaky
and disabling symptoms that make up the word "chemobrain." While
sometimes used derisively, sometimes jokingly, sometimes teasingly,
there is now no getting around the fact that administering chemotherapy
causes significant and demonstrable changes in brain metabolism.

            Makes sense, you think.

            And it does.  But common sense isn't science; and even those
medical professionals who listened sympathetically to their patients
had little to offer in return.  Part of the answer came in the way the
scientists approached the problem.

            Instead of studying chemotherapy's effect on the brain's
appearance, Rachael A Lagos, D.O., and colleagues at the West Virginia
Univeristy School of Medicine instead looked at its effect on brain function through an analysis of PET/CT brain imaging results utilizing special software.

 

 

             What a difference that made.  The proof was in the scans where "statistically significant decreases in regional brain metabolism" were noted.  Those changes were seen in areas associated with contentration and memory.

             Long story short:  your brain has as much difficulty processing chemotherapy drugs as the rest of your body does.



By now you all know that Robert Bazell, heath/science correspondent and author of The Making of Herceptin covered the story for NBC Nightly News and a crew came to talk with me yesterday morning about my chemobrain experience.

             My experience may have been different from yours.  Mine may
have lasted longer. You may have had sypmtoms that disappeared
overnight.  I don't know how much of the cognitive problems I
encountered can be attributed to chemo or simply the totality of
treatment --  radiation, multiple surgeries, and tamoxifen, the ultimate
in brain scrambling medications.  But I don't need a study or PET/scan
of my brain to say that definitively about Tamoxifen.  After seeing this
short and doable demonstration from a radiation resident (the RSNA
study was a poster session, mind you) from just ONE aspect of cancer
treatment is more than enough for me.

Exercise works for easing chemobrain. Truly does.

Now where we need to go is to continue the discussion on working through the disability.
That's why the crew filmed the additional segments that they did.
 Those weren't random.  Both cycling and quilting were activities I took
up AFTER treatment to help cope. There is no doubt that physical
exercise, intense aerobic activity, is one of the best possible things
you can do to cope with chemobrain, fatigue, and regain strength and
vitality.  Taking up quilting involved learning a compelte new set of
tasks, and yes, not seriously injuring myself or anyone else when using a
rotary cutter.  A third way to help anyone suffering cognitive
impairment would be assistance with organizational skills.  Anyone who
knows me and looks at my waning organizational skills can attest to
that. A good text on ADD probably woundn't hurt either.  Stress
management is also key.

Quilting is
something I took up after cancer treatment....it's soemthing creative
and stress managment all in one. Here I'm using English paper piecing of
3/4" hexagons. There's no way to machine piece them accurately.

With Debbie Strauss of NBC News.

          When I watched both the broadcast and web footage last
night  I was reminded that for many of us, the cancer itself wasn't a
problem but recovering from treatment WAS.  While we were talking
I told correspondent Debbie Strauss that during those difficult months I
remember staring at a blank piece of paper trying to write a simple
paragraph.

           A paragraph.  Something I used to do in my sleep.  Something I
could do upside down or inside out.  No, writing a paragraph has never
been the same.  But never has the sense of accomplishment carried such a
sweet ring, either. And that will always be enough.





More where this came from:

Reserarchers Find Evidence of Chemobrain

Healing from ChemoBrain Gradual



BoingBoing: Chemobrain....Isn't All in Your Head



Great blog on chemobrain  AnneMarie Ciccarella and this recommendation: Your Brain After Chemo, by journalist Idelle Davidson.

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Women with Cancer: Is Metastatic Breast Cancer on the Rise in Young W...

Is Metastatic Breast Cancer on the Rise in Young Women?

Something long noted in breast cancer circles was study coming out today in the Journal of the American Medical Association that
found a very small, but statistically significant, increase in the
number of young women between the ages of 25 to 39 who are diagnosed
with metastatic breast cancer.  

The change
noted comes down to an absolute increase of 1.37 women per 100,000 women
over 34 years, or approximately 2 percent per year. The same increase
was not noted in older women and was consistent across all ethnic and
socioeconomic groups.  One surprise is that there was a more pronounced
increased in women with hormone sensitive breast cancer, rather than ER-
cancer. 

Why this is
happening is yet to be determined and was not the purpose of the study.
We are left with more questions than answers.  

Studies are often complicated, and this one, a retrospective, observational analysis of three different
sets of incidence and survvial rates from the US Surveillance,
Epidemiology and End Results (SEER) program at the National Cancer
Institute from l976 through 2009 - even more so. The collection of SEER
data began in l973, yet the study years ran from 1976 - 2009.  Even the
largest data set used, SEER 18, only comprises 28 percent of the US
population.  SEER 9, by comparison, only includes 9.5% of the
population, and the third set, SEER 13, 15 percent.  

Study author
Rebecca Johnson, MD, Seattle Children's Hospital and University of
Washington, wrote in the study that, "Whatever the causes - and likely
there are more than 1 - the evidence we observed for the increasing
incidence of advanced breast cancer in young women will require
corroboration and may be best confirmed by data from other countries.
 If verified, the increase is particularly concerning, because young age
itself is an independent prognostic factor for breast cancer."

Vast
improvements in diagnostic imaging between 1976 and now, staging
work-ups and other factors come into play.  "The changes noted may be
multifactorial," said Jennifer Litton, MD, of The University of Texas MD
Anderson Cancer Center, "with changes in rates of incidence and younger
women having more aggressive underlying biologies  coupled with
potentially other genetic factors. What is much more clinically
important than this would be changes in overall survival."

Breast cancer
advocates concur. "These numbers do not change it for anyone who dies of
this disease today," said Joy Simha, co-founder of the Young Survival
Coalition. "We need to focus on finding the cause of breast cancer so we
can make change happen."

Another aspect
confirms what was discussed in last night's #BCSM discussion. "What the
study enforces to me is the need for all young women to be aware of
changes and to be proactive about their health," said Deanna Attai, MD,
breast surgeon and #BCSM comoderator.  "Doctors need to be educated that
there's no such things as "too young for breast cancer." No such
thing."

For women with
breast cancer today?  Nothing changes.  If you're in treatment today?
Nothing changes.  But if you're watching the larger picture of cancer
incidence in the United States in a population that already suffers
unduly from a breast cancer diagnosis?  Heads up.  This is a signal we
need to heed. 

#   #   #

3/3/2013:
 Comments from Ann Partdridge, MD:  breast medical oncologist from the
Dana Farber Cancer Institute in Boston and medical advisor to the Young
Survival Coalition: 

It
is not clear from the study "whether the overall rate of breast cancer
in young women is actually increasing," said Ann Partridge, MD, a
medical oncologist from the Dana-Farber Cancer Institute and Harvard
Medical School in Boston, Massachusetts. In other words, the study does
not indicate whether the increase in advanced disease means that there
is an overall increase in disease in young women.

That is
important because other studies using SEER data have indicated that the
rate of overall disease is stable in young women, said Dr. Partridge.

She pointed
out that Dr. Johnson and colleagues found that the rates of localized
and regional disease held steady in young women. Therefore, because they
found an increase in advanced disease, thereshould be an overall increase in young women, she said.

However, the
researchers "did not show/discuss data on overall rates of breast cancer
in young women," Dr. Partridge wrote in an email. This omission,
combined with the fact that the study findings might be in conflict with
findings from other studies using SEER data, "leads me to wonder about
the article," she said.

Check out the rest of the article and others: 

From Liz Szabo, USA Today:  "Deadly Breast Cancers are Rising in Young Women"

From the NYTimes:   "Study Finds More Breast Cancer at Young Age"

From NPR:  "Younger Women Have Rising Rate of Advanced Breast Cancer Study Says" 

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Survivorship Guidelines. For real.

Survivorship Guidelines. For real.

 

 

Late last week the National Comprehensive Cancer Network (NCCN), a nonprofit alliance of 21 comprehensive cancer centers, announced its first ever set of clinical practice guidelines for survivorship care.

     There are
some 13.7 million cancer survivors in the United States alone. Of those,
2.9 million are breast cancer survivors. All of us have found our way
through those first difficult months and years following diagnosis.
Treatment itself was one thing. Trying to adjust to life after cancer
was another.

      But by any measure the guidelines are good news for any man or woman in treatment now. The 100-page report covers eight distinct areas:

• anxiety and depression
• cognitive function
• exercise 
• fatigue
• immunizations and infections
• pain
• sexual function 
• sleep disorders. 

         
 Standards for evidence-based survivorship care are only being developed
now. The first conference on survivorship science as an entity in and
of itself did not take place until 2003. In 2004, the CDC and Livestrong
published "A National Cancer Action Plan for Cancer Survivorship,"
which included the simple, yet powerful recommendation to establish an infrastructure
for a comprehensive database on cancer survivorship. I don't know if
that has transpired.  While that sounds smart to me, making smart things
happen is not one of the hallmarks of our framented health care system.  

           Then as most of you know, in 2005 the Institute of Medicine published its landmark consensus report Lost in Transition, which made the case for survivorship care. Six years later Livestrong
held a collaborative symposium of stakeholders, health care
professionals and advocates to begin a consenus building project to
articulate the "essential" elements in surivorship care. 

            A
later IOM report, "From Cancer Care for the Whole Patient: Meeting
Psychosocial Health Needs," recommended that psychosocial screening be
part of quality cancer care.  This is well covered in NCCN guidlines but
why other concepts from Lost in Transition and Elements
didn't become part of NCCN's report aren't clear, even though both
reports are mentioned. NCCN surivorship care guidlines, for example,
don't even support the need for a survivorhip care plan or treatment
summary. While we all understand that there's no economic incentive in
place for this let's get serious. A one page print out is not rocket
science. Both "Lost" and "Elements" stress the need for education - of
providers and patients - and coordination of care. NCCN's guidelines
don't venture that far.

            NCCN's guidelines are
directed at professionals. How this material will make its way from the
nation's 21 comprehensive cancer centers to the community setting,
where the majority of women are seen, is not explained. Color me
skeptical but I see a packet of information stacked on an oncologist's
already stacked desk. Neither were there any outside patient advocates or
organizations on the committees as listed in the report. This makes no
sense to me. You'd think that patient advocacy networks would be tapped
for their assistance and guidance in moving this material to where it
needs to be. Let patients know and let them help. No one is more invested in assuring the provision of good survivorship care than we are. 

          A few other take-aways to the report:

• at least
  50% of (all) survivors suffer from some late effect of cancer treatment.
  The most common problems seen are pain, depression and fatigue.
• anxiety and
  depression affect up to 29 percent of all survivors; and some 19% meet
  the diagnostic criteria for post-traumatic stress syndrome.
• the
  increasing trend toward more treatment, combined chemo, radiation,
  hormone therapy and surgery can result in more late effects. One example
  was the study from last week on increased of heart disease for women
  receiving radiation therapy.

         
Believe me, I am far from done with this topic. Sometimes It seems the
more we do to treat - not cure - cancer - the more potential for
problems there are down the road.  We can't go back and undo treatment
we selected, decisions we made when faced with a difficult, confounding
disease. I do believe we can do a better job with survivorship though,
and these guidelines are one place to start.

          I
hope you'll take a look at the report. You will need to establish an
account but you can access the material by registering with your email
address here:

       

#   #   #

Interesting
note:  I just saw a news release from NCCN announcing that two
additional cancer centers have been added to their network.  They are UC
San Diego Moores Cancer Ceneter and University of Colorado Cancer
Center.

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Women with Cancer: Cancer: Round Two

Women with Cancer: Cancer: Round Two: This is how things change. On Tuesday, April 9 we celebrate DH's (darling husband's) birthday with an extravagant dinner with f...

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Cancer and My Marriage

Note: Ask any survivor about
side-effects or working with an oncologist and you’ll receive a
notebook’s worth of helpful information. Ditto for managing cancer on
the job or with children. But ask them about their relationship and
you’re apt to hear variations on this theme, “He never blinked,” or “He
really showed me how strong a man he truly is.” In other words, you’re
not apt to hear what it’s truly like for some women. While we celebrate
relationships where love’s better nature rules, it’s also time to
honestly share the kind of stress cancer and its associated treatment
brings to many two-income families where jobs, children, carpools and
chemotherapy all need to be balanced in the course of a day. I was asked
by a woman whom I admire to publish this essay here. It is my honor to
do so.

 --- Jody Schoger

I never thought I would write an anonymous blog post.

Nonetheless, here I am, writing
about cancer’s impact on my marriage after my late-night Google searches
only yielded stories of marital triumph, replete with images of the
devoted spouse proffering a tender kiss on his partner’s bald head. My
hope is that the next despondent, lonely cancer patient might feel a
little less crazy reading my story

I love my husband and do not want to be disloyal to him. I will remain strategically vague on some details and alter others to shield
my family’s privacy. We have had the kind of marriage people say they
can bet on. Single friends confess that they hope to find a partnership
like ours. Obviously, things are always messier on the inside, but we
undoubtedly share a strong love for and commitment to one another.

When I was diagnosed we’d been
married with children for more than a decade. Like every couple we had
our strengths and weaknesses. We were strong in the communication
department, which allowed us to navigate the transitions of parenthood,
moves and job changes.

Even with these strengths at our
disposal, nothing challenged our relationship like my cancer diagnosis. I
was in treatment for almost a year, with follow-up drugs and surgeries
that impacted my quality of life for a prolonged long period of time,
far longer than either one of us expected. I had chemo, a mastectomy and
radiation which was then followed by a series of reconstructive surgeries. All the while, I held down a job, tried to help raise my children and hold things together.

Our marital glue was communication,
adventure, and sex. Chemobrain wiped out my ability to communicate,
especially about emotional issues. Strong emotions made me queasy, leading
me to shut down even more. Also, my forgetfulness was a constant source
of frustration to my husband, who came to treat me like one of the
children, nagging and cajoling me.



The painful truth was that he
wasn’t totally off-base in doing this. He had to keep the household
together, and I was falling apart. As for adventure, it is hard to be
spontaneous when you are immunocompromised, nauseated and unprepared for the undertow of fatigue that can pull
you in and wipe you out. And of course, our sex life was horribly
disrupted. Given the length of our relationship and the presence of
children, we were surprisingly regular in our sexual activity. Chemo
brought on chemical menopause; the mastectomy took away a critical
erogenous zone and left me with profound loss of body confidence.
Radiation, for me, was painful and a complete energy drain. All this
together is the opposite of sexy.

I have read accounts of the
sympathetic, supportive husbands who wait patiently for a partner to
heal. My husband was like this probably two-thirds of the time. But he
is only human. All the things I couldn’t do he did ... from driving
carpools, cleaning the house, doing laundry, communicating with
teachers, mediating sibling spats, and tween-age drama. He was holding down his own job, and could only watch as the little energy I had energy my went to my work. By the time I arrived home I was completely spent and totally unavailable emotionally or sexually.

Plus my bitterness at the length of treatment grew as the months dragged on. If it had been a month or two, I
think we could have endured it and come out relatively unscathed. But
this has gone on for years. Not only was this ordeal loosening our glue,
but the
friction points of marriage – the ways we see things so differently ––
began to push us further apart. Because of my limited energy and
concentration, we couldn’t have one of our major realignment
conversations that used to bring us back to a place of mutual
understanding and respect about our differences. Add to this mix the
financial strain of decreased income and increased expenses. A chunk of
my income comes from freelance work, which was now off the table because
of my illness. Even though we have good insurance, I was stunned at how
quickly medication co-pays and deductibles added up to big numbers.
Money is the source of conflict even in stable situations and we began to argue about purchases that never were an issue before.

Eventually we hit several crisis points. There were the periodic pity parties my husband had about his utter deprivation, emotionally,
physically and sexually. It was a stretch for me to comfort him, since
he was basically right. Guys really don’t reach out to other men when
they are vulnerable. Where I am sure my girlfriends would have rallied
to my side had our roles been reversed, he was left basically alone.
None of our extended family members live near us. There wasn’t a
grandparent, an aunt or even a cousin to give him a break for any length
of time.  Nor did it help our
bond that he was petrified at the idea of actually losing me. At his
lowest moments, he would vacillate between his frustration with my
helplessness and the terror of my possible death. He
told me through tears one day, "I can't stand that the one person I
want to talk about all this with is you, and you are really not really
able to talk."

Another crisis came after my
treatment was over and I started to regain my cognitive and physical
energy. It would no longer do for him to treat me like his other child.
But it takes more than a simply saying, “Mom’s back in business.” The
children had learned that Dad was the Real Parent in the house, an idea
reinforced by the ways he would second-guess my authority as a mother.
It was difficult to stand up to this. How do you stake a claim to your
authority when you are not the same in memory, strength, or energy? I
confronted him about this. To his great credit, he has worked with me to
rebalance our parenting team, with the understanding that I am still
not 100 percent. Regaining authentic balance in our partnership remains an ongoing challenge.

Our sex life is on the mend but is
still a source of strife. I have not figured out how to feel comfortable
naked, with all the scars riddling my torso and the false breast that
feels numb and dead. My energy remains unreliable. At night, once the
dishes are washed and the children tucked in, I often want to crawl in
the bed to sleep. We are trying to be more deliberate about carving out
time for ourselves and our relationship, but it is so hard. So, so hard.

There is a lot of talk in the
cancer world about survivorship plans for patients. What I really need
is a survivorship plan for my marriage. In my support group, I see a lot
of people getting divorced after the crisis of treatment subsides.
These wounds cut deep, touching our greatest insecurities. Luckily, I do
know a handful of survivors whose marriages did recover. I just wish I
had more of a roadmap for how to steer my marriage toward success and
away from the potential disaster.

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Gynecological Tumours

Cervix uteri and corpus uteri were among the first sites to be classified by the TNM system. The "League of Nations" stages for carcinoma of the cervix have been used with minor modifications for over 50 years, and, because these are accepted by the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO), the TNM categories have been defined to correspond to the FIGO stages. Some amendments have been made in collaboration with FIGO, and the classifications now published have the approval of the FIGO, UICC, and the national TNM committees including the AJCC.
Each site is described under the following headings:

• Rules for classification with the procedures for assessing T, N, and M categories; additional methods may be used when they enhance the accuracy of appraisal before treatment
• Anatomical subsites where appropriate
• Definition of the regional lymph nodes
• TNM Clinical classification
• pTNM Pathological classification
• Stage grouping
• Summary

2. Distant Metastasis

The categories M1 and pM1 may be further specified according to the following notation:

Pulmonary PUL Bone marrow MAR Osseous OSS Pleura PLE Hepatic HEP Peritoneum PER Brain BRA Adrenals ADR Lymph nodes LYM Skin SKI Others OTH

3. Histopathological Grading

The definitions of the G categories apply to all classified tumours except gestational trophoblastic tumours. These are:

GX. Grade of differentiation cannot be assessed
G1. Well differentiated
G2. Moderately differentiated
G3. Poorly differentiated or undifferentiated

4. R Classification

The absence or presence of residual tumour after treatment is described by the symbol R. The definitions of the R classification are:
RX. Presence of residual tumour cannot be assessed
R0. No residual tumour
R1. Microscopic residual tumour
R2. Macroscopic residual tumour

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Gestational Trophoblastic Tumours

1. Rules for Classification

The following classification for gestational trophoblastic tumours is based on that of FIGO adopted in 1992 and updated in 2001 (Gestational trophoblastic tumours. Ngan HYS, Odicino F, Maisonneuve P, Beller U, Benedet JL, Heintz APM, Pecorelli S, Sideri M, Creasman WT. J Epidemiol Biostatist 2001;6:175-184). The definitions of T and M categories correspond to the FIGO stages. Both systems are included for comparison. In contrast to other sites, an N (regional lymph node) classification does not apply to these tumours. A prognostic scoring index, which is based on factors other than the anatomic extent of the disease, is used to assign cases to high risk and low risk categories, and these categories are used in stage grouping.

The classification applies to choriocarcinoma (9100/3), invasive hydatidiform mole (9100/1), and placental site trophoblastic tumour (9104/1). Placental site tumours should be reported separately. Histological confirmation is not required if the human chorionic gonadotropin (hCG) level is abnormally elevated. History of prior chemotherapy for this disease should be noted.

The following are the procedures for assessing T and M categories:

T categories. Physical examination, imaging including urography and cystoscopy
M categories. Physical examination and imaging
Risk categories. Age, type of antecedent pregnancy, interval from index pregnancy, pretreatment hCG, diameter of largest tumour, site of metastasis, number of metastases, and antecedent treatment are integrated to provide a prognostic score that divides cases into low and high risk categories.

2.1. Primary Tumour

TM Categories FIGO Stages * TX Primary tumour cannot be assessed T0 No evidence of primary tumour T1 I Tumour confined to uterus T2 II Tumour extends to other genital structures: vagina, ovary, broad ligament, fallopian tube by metastasis or direct extension M1a III Metastasis to lung(s) M1b IV Other distant metastasis

^*Note: Stages I to IV are subdivided into A and B according to the prognostic score.

2.2. M - Distant Metastasis

MX. Metastasis cannot be assessed
M0. No distant metastasis
M1. Distant metastasis
  M1a. Metastasis to lung(s)
  M1b. Other distant metastasis
Note: Genital metastasis (vagina, ovary, broad ligament, fallopian tube) is classified T2. Any involvement of non-genital structures, whether by direct invasion or metastasis is described using the M classification.

3. pTM Pathological Classification

The pT and pM categories correspond to the T and M categories.

4. Prognostic Score

Prognostic Factor 0 1 2 4 Age <40 ≥40 Antecedent pregnancy H. mole Abortion Term pregnancy Months from index pregnancy <4 4-<7 7-12 >12 Pretreatment serum hCG (IU/ml) <103 103-<104 104-<105 ≥105 Largest tumour size including uterus <3 cm 3-<5 cm ≥5 cm Sites of metastasis Lung Spleen, kidney Gastrointes-tinal tract Liver, brain Number of metastasis 1-4 5-8 >8 Previous failed chemotherapy Single drug Two or more drugs

5. Stage Grouping

Stage T M Risk Category I T1 M0 Unknown IA T1 M0 Low IB T1 M0 High II T2 M0 Unknown IIA T2 M0 Low IIB T2 M0 High III Any T M1a Unknown IIIA Any T M1a Low IIIB Any T M1a High IV Any T M1b Unknown IVA Any T M1b Low IVB Any T M1b High

6. Summary

TM and risk Gestational Trophoblastic Tumours Stage T1 Confined to uterus I T2 Other genital structures II M1a Metastasis to lung(s) III M1b Other distant metastasis IV Low risk Prognostic score 7 or less IA-IVA High risk Prognostic score 8 or more IB-IVB

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Gynecological Tumours Fallopian Tube

Introduction

The following classification for carcinoma of the fallopian tube is based on that of FIGO adopted in 1992. The definitions of the T, N, and M categories correspond to the FIGO stages. Both systems are included for comparison.

1. Rules for Classification

The classification applies only to carcinoma. There should be histological confirmation of the disease.

The following are the procedures for assessing T, N, and M categories:

T categories. examination, imaging, laparoscopy, and/or surgical exploration
N categories. Physical examination, imaging, laparoscopy, and/or surgical exploration
M categories. Physical examination, imaging, laparoscopy, and/or surgical exploration

The FIGO stages are based on surgical staging. (TNM stages are based on clinical and/or pathological staging.)

2. Regional Lymph Nodes

The regional lymph nodes are the hypogastric (obturator), common iliac, external iliac, lateral sacral, para-aortic, and inguinal nodes.

3. TNM Clinical Classification

3.1. T - Primary Tumour

TNM Categories FIGO Stages TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis 0 Carcinoma in situ (preinvasive carcinoma) T1 I Tumour confined to fallopian tube(s) T1a IA Tumour limited to one tube, without penetrating the serosal surface T1b IB Tumour limited to both tubes, without penetrating the serosal surface T1c IC Tumour limited to one or both tube(s) with extension onto or through the tubal serosa, or with malignant cells in ascites or peritoneal washings T2 II Tumour involves one or both fallopian tube(s) with pelvic extension T2a IIA Extension and/or metastasis to uterus and/or ovaries T2b IIB Extension to other pelvic structures T2c IIC Pelvic extension (2a or 2b) with malignant cells in ascites or peritoneal washings T3 and/or N1 III Tumour involves one or both fallopian tube(s) with peritoneal implants outside the pelvis and/or positive regional lymph nodes T3a IIIA Microscopic peritoneal metastasis outside the pelvis T3b IIIB Macroscopic peritoneal metastasis outside the pelvis 2 cm or less in greatest dimension T3c and/or N1 IIIC Peritoneal metastasis more than 2 cm in greatest dimension and/or positive regional lymph nodes M1 IV Distant metastasis (excludes peritoneal metastasis)

Note: Liver capsule metastasis is T3/stage III, liver parenchymal metastasis, M1/ stage IV. Pleural effusion must have positive cytology for M1/stage IV.

3.2. N - Regional Lymph Nodes
NX. Regional lymph nodes cannot be assessed N0. No regional lymph node metastasis N1. Regional lymph node metastasis
3.3. M - Distant Metastasis
MX. Distant metastasis cannot be assessed M0. No distant metastasis M1. Distant metastasis

4. pTNM Pathological Classification

The pT, pN, and pM categories correspond to the T, N, and M categories.

pN0. Histological examination of a pelvic lymphadenectomy specimen will ordinarily include 10 or more lymph nodes. If the examined lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0.

5. G Histopathological Grading

GX. Grade of differentiation cannot be assessed
G1. Well differentiated
G2. Moderately differentiated
G3. Poorly differentiated
G4. Undifferentiated

6. Stage Grouping

Stage 0 Tis N0 M0 Stage IA T1a N0 M0 Stage IB T1b N0 M0 Stage IC T1c N0 M0 Stage IIA T2a N0 M0 Stage IIB T2b N0 M0 Stage IIC T2c N0 M0 Stage IIIA T3a N0 M0 Stage IIIB T3b N0 M0 Stage IIIC T3c N0 M0 Any T N1 M0 Stage IV Any T Any N M1

7. Summary

TNM Fallopian Tube FIGO T1 Limited to tube(s) I T1a One tube; serosa intact IA T1b Both tubes; serosa intact IB T1c Serosa involved; malignant cells in ascites or peritoneal washings IC T2 Pelvic extension II T2a Uterus and/or ovaries IIA T2b Other pelvic structures IIB T2c Malignant cells in ascites or peritoneal washings IIC T3 and/or N1 Peritoneal metastasis outside the pelvis and/or regional lymph node metastasis III T3a Microscopic peritoneal metastasis IIIA T3b Macroscopic peritoneal metastasis ≤2 cm IIIB T3c and/or N1 Peritoneal metastasis >2 cm and/or regional lymph node metastasis IIIC M1 Distant metastasis (excludes peritoneal metastasis) IV

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