My Doctor Online The Permanente Medical Group

Symptoms

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Patients frequently ask: "What should I look out for?" or "What symptoms should worry me?"

In general, symptoms caused by cancer depend on the cancer's size and location. A cancer that starts or spreads to the bones may or may not cause pain at the site to which it has spread. Because a tumor may grow slowly over several months, symptoms may gradually increase over time. For this reason, symptoms that occur over time may be less noticeable than a more acute, more immediate set of symptoms that have "come and gone."

Regardless of the type of cancer, it is important to remember that symptoms can differ enormously from patient to patient. Some patients have no symptoms whatsoever, even if they have a large tumor, while other patients may experience symptoms that mimic common, less serious diseases. Cancers of the lung, breast, colon, or cervix can have their own set of symptoms that may or may not be present in every patient.

Screening

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The term "screening" refers to testing to look for any signs of early cancer. The hope is that a cancer will be found early, when it can be more easily treated. If cancer is discovered at a later stage, when it might be more advanced, it can be more difficult to treat. Screening is much more successful, therefore, in organs where removing a small, harmless abnormality poses minimal risk to the patient. This is particularly true of cancers of the cervix, colon, and breast, for which early detection has improved outcomes.

In some instances, increased screening can also result in "false positives," where growths that initially seem like cancer do not turn out to be. In addition, for some individuals, "watchful waiting," a supervised monitoring of the disease over time, rather than treatment, may also be advisable.

Diagnosis

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While cancer may be suspected based upon an exam, lab findings, or X-rays, the gold standard for making a diagnosis is the biopsy.

A biopsy is a procedure in which a piece of tissue is removed from the body and examined by a physician specialist called a pathologist.

Often the tissue is sent to a specialized laboratory where it is subjected to analysis (called immune histochemistry) or to a variety of molecular tests that look for unique changes in the DNA of the tumor cells. These newer genetic tests often take time to perform and can lead to frustration for the patient who is anxious to receive the results. It is useful to remember that these newer, often time-consuming technologies help us arrive at an accurate diagnosis.

Staging

If there are any questions that we can predict will be on the mind of our cancer patients, they are: "What does the future hold?" and "What are my treatment options?"

It is the usual practice to look at the unique features of each patient's cancer to glean clues about how that patient is likely to do. Often we assign a "stage" to a cancer. The term stage refers to one of several systems that categorize how far a particular cancer has spread. Cancers that are small and remain localized are generally assigned to a lower stage, while cancers that have spread to lymph nodes or some distant site are generally given a higher stage. Patients with low-stage cancers generally do better than those with more advanced-stage cancers.

The pathologist (the doctor who stages the cancer) also usually assigns a "grade" to the cancer. Cancer cells arise from normal tissue made up of normal cells that have undergone a process called "differentiation." When a cell differentiates, it develops the features and appearance unique to the tissue of which it is a part. The more differentiated a cancer cell is – that is, the more it resembles a normal cell – the lower its grade. A high-grade cancer often bears little resemblance to the tissue from which it arose.

Increasingly, with modern scientific tools, we are discovering other features that help us categorize a cancer. The newer categorizations usually rely on molecular or genetic changes in cancer cells that can be measured with an array of new, modern technologies.

At Kaiser Permanente, we have several laboratories that specialize in molecular, genetic, or immunohistochemical analyses of cancers. Because of our expertise, we are able to analyze cancer specimens with an extremely high level of sophistication. Increasingly, these newer techniques are being used to supplement more traditional diagnostic tools to provide physicians and patients with insight into possible outcomes (prognosis).

Even with all of these tools, predicting the long-term outcome for an individual patient is an informed guess. In many situations, we have experience based on large numbers of patients and can often tell a patient what happens "on average" to patients like themselves. However, an average implies that half (50 percent) of patients do better than average and the other half (the other 50 percent) do worse. While we always hope that all of our patients will do better than average, it is probably prudent for patients to think about several possible outcomes.

Treatments

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Cancer treatments often involve:

• Surgery
• Radiation therapy
• Chemotherapy, also known as drug therapy

Treatment plans can usually include a combination of these treatment methods. For some patients, a supervised observation, also known as "watchful waiting," might be the best approach.

Surgery

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With some exceptions, surgery is usually considered part of a treatment plan. Surgery can be particularly effective for a cancer that is localized, meaning it has not spread or metastasized to distant sites.

Surgery is a good treatment option for certain types of cancer if:

• They are localized.
• They are in an operable location.
• Surgery is compatible with the patient's overall health status.

It is generally up to the surgeon to determine whether to use specialized, high-tech tools such as a laparoscope, thoracoscope, lasers, or even robots.

Radiation Therapy

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Radiation therapy refers to cancer treatment through the use of high-energy radiation beamed at the tumor. This can be quite useful in many situations, but the side effects of radiation depend on the volume of tissue being targeted and the organs that may be included in the "target area." For these reasons, radiation is usually used only when a small area of the body needs to be treated or when the cancer is located in an area of the body relatively resistant to the effects of radiation.

A physician who specializes in administering radiation therapy is called a radiation oncologist.

Chemotherapy (Drug Therapy)

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Chemotherapy is often used to describe a specific category of drug treatments for cancer. The chemotherapy drugs kill the cancer cells to help prevent them from growing and spreading. Typically, chemotherapy is administered intravenously (through an IV needle) or taken orally (by mouth). The type of chemotherapy given to a patient depends upon the type and stage of the cancer. You can better understand what to expect during chemotherapy using our Emmi tool.

There are also other types of drug treatment for cancer, including hormone therapy and even biologic therapy. Hormonal agents are frequently used to treat many breast cancers and prostate cancer. Biologic agents (also known as "targeted therapies") refer to a group of high-tech treatments that have arisen from our increased understanding of the molecular causes of cancer.

Clinical Trials

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We may also discuss with you the possibility of enrolling in a clinical trial. Clinical trials are research studies designed to improve treatment for cancer patients. Some trials investigate new cancer drugs and treatments while others compare standard treatments with new treatments.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours per day, 7 days per week.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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