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Xpovio (selinexor) for Multiple Myeloma: Side Effects & Dosage

Generic drug: selinexor

Brand name: Xpovio

What is Xpovio (selinexor), and how does it work?

Xpovio is a prescription medicine used:

in combination with dexamethasone to treat adults with multiple myeloma (MM) that has come back (relapsed) or that did not respond to previous treatment (refractory), and
- who have received at least 4 prior therapies, and
- whose disease did not respond to (refractory) to at least 2 proteasome inhibitor medicines, at least 2 immunomodulatory agents, and an anti-CD38 monoclonal antibody medicine.
to treat adults with certain types of diffuse large B-cell lymphoma (DLBCL) that has come back (relapsed) or that did not respond to previous treatment (refractory) and who have received at least 2 prior therapies It is not known if Xpovio is safe and effective in children less than 18 years of age.

What are the side effects of Xpovio?

Xpovio can cause serious side effects, including:

Nausea and vomiting.
Nausea and vomiting are common with Xpovio and can sometimes be severe.
Nausea and vomiting may affect your ability to eat and drink well. You can
lose too much body fluid and body salts (electrolytes) and may be at risk
for becoming dehydrated. You may need to receive intravenous (IV) fluids or
other treatments to help prevent dehydration. Your healthcare provider will
prescribe anti-nausea medicines for you to take before you start and during
treatment with Xpovio.
Diarrhea. Diarrhea is common with Xpovio and can sometimes be severe. You can lose too much body fluid and body salts (electrolytes) and may be at risk for becoming dehydrated. You may need to receive IV fluids or other treatments to help prevent dehydration. Your healthcare provider will prescribe anti-diarrhea medicine for you as needed.
Loss of appetite and weight loss. Loss of appetite and weight loss are common with Xpovio and can sometimes be severe. Tell your healthcare provider if you have a decrease or loss of appetite and if you notice that you are losing weight. Your healthcare provider may prescribe medicines that can help increase your appetite or prescribe other kinds of nutritional support.
Decreased sodium levels in your blood. Decreased sodium levels in your blood is common with Xpovio but can also sometimes be severe. Low sodium levels in your blood can happen if you have nausea, vomiting, or diarrhea, you become dehydrated, or if you have loss of appetite with Xpovio. You may not have any symptoms of a low sodium level. Your healthcare provider may talk with you about your diet and prescribe IV fluids for you based on the sodium levels in your blood. Your healthcare provider will do blood tests before you start taking Xpovio, and often during the first 2 months of treatment, and then as needed during treatment to monitor the sodium levels in your blood.
Serious infections. Infections are common with Xpovio and can be serious and can sometimes cause death. Xpovio can cause infections including upper or lower respiratory tract infections, such as pneumonia, and an infection throughout your body (sepsis). Tell your healthcare provider right away if you have any signs or symptoms of an infection such as cough, chills or fever, during treatment with Xpovio.
Neurologic side effects. Xpovio can cause neurologic side effects that can sometimes be severe and life-threatening.
- Xpovio can cause dizziness, fainting, decreased alertness, and changes in your mental status including confusion and decreased awareness of things around you (delirium).
- In some people, Xpovio may also cause problems with thinking (cognitive problems), seeing or hearing things that are not really there (hallucinations), and may become very sleepy or drowsy.

Tell your healthcare provider right away if you get any of these signs or symptoms.

Your healthcare provider may change your dose of Xpovio, stop your treatment for a period of time, or completely stop your treatment if you have certain side effects during treatment with Xpovio.

Common side effects of Xpovio include:

tiredness
low red blood cell count (anemia). Symptoms may include tiredness and shortness of breath.
constipation
shortness of breath
increased blood sugar
changes in body salt and mineral levels in your blood
changes in kidney and liver function blood tests

Xpovio may cause fertility problems in males and females, which may affect your ability to have children. Talk to your healthcare provider if you have concerns about fertility.

These are not all the possible side effects of Xpovio.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What is the dosage for Xpovio?

Recommended Dosage For Multiple Myeloma

In Combination With Bortezomib And Dexamethasone (SVd)

The recommended dosage of
Xpovio is 100 mg taken orally once weekly on Day 1 of each week until disease progression or unacceptable toxicity in combination with:

Bortezomib 1.3 mg/m² administered subcutaneously once weekly on Day 1 of each week for 4 weeks followed by 1 week off.
Dexamethasone 20 mg taken orally twice weekly on Days 1 and 2 of each week.

Refer to the prescribing information of bortezomib and dexamethasone for additional dosing information.

In Combination With Dexamethasone (Sd)

The recommended dosage of Xpovio is 80 mg taken orally on Days 1 and 3 of each week until disease progression or unacceptable toxicity in combination with dexamethasone 20 mg taken orally with each dose of
Xpovio on Days 1 and 3 of each week.
For additional information regarding the administration of dexamethasone, refer to its prescribing information.

Recommended Dosage For Diffuse Large B-Cell Lymphoma

The recommended dosage of Xpovio is 60 mg taken orally on Days 1 and 3 of each week until disease progression or unacceptable toxicity.

Recommended Monitoring For Safety

Monitor complete blood count (CBC) with differential, standard blood chemistries, body weight, nutritional status, and volume status at baseline and during treatment as clinically indicated.
Monitor more frequently during the first three months of treatment.
Assess the need for dosage modifications of Xpovio for adverse
reactions.

Recommended Concomitant Treatments

Advise patients to maintain
adequate fluid and caloric intake throughout treatment. Consider intravenous
hydration for patients at risk of dehydration.

Provide prophylactic
antiemetics. Administer a 5-HT3 receptor antagonist and other anti-nausea agents
prior to and during treatment with Xpovio.

Dosage Modification For Adverse Reactions

Recommended
Xpovio dosage reduction steps are presented in Table 1.

Table 1:
Xpovio Dosage Reduction Steps for Adverse Reactions

Multiple Myeloma In Combination with Bortezomib and Dexamethasone (SVd)Multiple Myeloma In Combination with Dexamethasone (Sd)Diffuse Large B-Cell LymphomaRecommended Starting Dosage100 mg once weekly80 mg Days 1 and 3 of each week
(160 mg total per week)60 mg Days 1 and 3 of each week
(120 mg total per week)First Reduction80 mg once weekly100 mg once weekly40 mg Days 1 and 3 of each week
(80 mg total per week)Second Reduction60 mg once weekly80 mg once weekly60 mg once weeklyThird Reduction40 mg once weekly60 mg once weekly40 mg once weeklyFourth ReductionPermanently discontinuePermanently discontinuePermanently discontinue

Recommended dosage modifications for hematologic adverse reactions in patients with multiple myeloma and DLBCL are presented in Table 2 and Table 3, respectively. Recommended dosage modifications for nonhematologic adverse reactions are presented in Table 4.

Table 2:
Xpovio Dosage Modification Guidelines for Hematologic Adverse Reactions in Patients with Multiple Myeloma

Adverse ReactionOccurrenceActionThrombocytopenia Platelet count 25,000 to less than 75,000/mcLAny

Reduce
Xpovio by 1 dose level (see Table 1).

Platelet count 25,000 to less than 75,000/mcL with concurrent bleedingAny

Interrupt
Xpovio.
Restart Xpovio at 1 dose level lower (see Table 1) after bleeding has resolved.
Administer platelet transfusions per clinical guidelines.

Platelet count less than 25,000/mcLAny

Interrupt
Xpovio.
Monitor until platelet count returns to at least 50,000/mcL.
Restart
Xpovio at 1 dose level lower (see Table 1).

Neutropenia Absolute neutrophil count of 0.5 to 1 x 10⁹/L without feverAny

Reduce
Xpovio by 1 dose level (see Table 1).

Absolute neutrophil count less than 0.5 x 10⁹/L
OR
febrile neutropeniaAny

Interrupt
Xpovio.
Monitor until neutrophil counts return to 1 x 10⁹/L or higher.
Restart
Xpovio at 1 dose level lower (see Table 1).

AnemiaHemoglobin less than 8 g/dLAny

Reduce
Xpovio by 1 dose level (see Table 1).
Administer blood transfusions per clinical guidelines.

Life-threatening consequencesAny

Interrupt
Xpovio.
Monitor hemoglobin until levels return to 8 g/dL or higher.
Restart
Xpovio at 1 dose level lower (see Table 1).
Administer blood transfusions per clinical guidelines.

Table 3:
Xpovio Dosage Modification Guidelines for Hematologic Adverse Reactions in Patients with Diffuse Large B-Cell Lymphoma

Adverse ReactionOccurrenceActionThrombocytopenia Platelet count 50,000 to less than 75,000/mcLAny

Interrupt one dose of
Xpovio.
Restart Xpovio at the same dose level.

Platelet count 25,000 to less than 50,000/mcL without bleeding1st

Interrupt
Xpovio.
Monitor until platelet count returns to at least 50,000/mcL.
Reduce
Xpovio by 1 dose level (see Table 1).

Platelet count 25,000 to less than 50,000/mcL with concurrent bleedingAny

Interrupt
Xpovio.
Monitor until platelet count returns to at least 50,000/mcL.
Restart
Xpovio at 1 dose level lower (see Table 1), after bleeding has resolved.
Administer platelet transfusions per clinical guidelines.

Platelet count less than 25,000/mcLAny

Interrupt
Xpovio.
Monitor until platelet count returns to at least 50,000/mcL.
Restart
Xpovio at 1 dose level lower (see Table 1).
Administer platelet transfusions per clinical guidelines.

Neutropenia Absolute neutrophil count of 0.5 to less than 1 x 10⁹/L without fever1st occurrence

Interrupt
Xpovio.
Monitor until neutrophil counts return to 1 x 10⁹/L or higher.
Restart
Xpovio at the same dose level.

Recurrence

Interrupt
Xpovio.
Monitor until neutrophil counts return to 1 x 10⁹/L or higher.
Administer growth factors per clinical guidelines.
Restart
Xpovio at 1 dose level lower (see Table 1).

Absolute neutrophil count less than 0.5 x 10⁹/L
OR
Febrile neutropeniaAny

Interrupt
Xpovio.
Monitor until neutrophil counts return to 1 x 10⁹/L or higher.
Administer growth factors per clinical guidelines.
Restart
Xpovio at 1 dose level lower (see Table 1).

AnemiaHemoglobin less than 8 g/dLAny

Reduce
Xpovio by 1 dose level (see Table 1).
Administer blood transfusions per clinical guidelines.

Life-threatening consequencesAny

Interrupt
Xpovio.
Monitor hemoglobin until levels return to 8 g/dL or higher.
Restart
Xpovio at 1 dose level lower (see Table 1).
Administer blood transfusions per clinical guidelines.

Table 4:
Xpovio Dosage Modification Guidelines for Non–Hematologic Adverse Reactions

Adverse ReactionOccurrenceActionNausea and Vomiting Grade 1 or 2 nausea (oral intake decreased without significant weight loss, dehydration or malnutrition)
OR
Grade 1 or 2 vomiting (5 or fewer episodes per day)Any

Maintain
Xpovio and initiate additional anti-nausea medications.

Grade 3 nausea (inadequate oral caloric or fluid intake)
OR
Grade 3 or higher vomiting (6 or more episodes per day)Any

Interrupt
Xpovio.
Monitor until nausea or vomiting has resolved to Grade 2 or lower or baseline.
Initiate additional anti-nausea medications.
Restart
Xpovio at 1 dose level lower (see Table 1).

Diarrhea Grade 2 (increase of 4 to 6 stools per day over baseline)1^st

Maintain
Xpovio and institute supportive care.

2^nd and subsequent

Reduce
Xpovio by 1 dose level (see Table 1).
Institute supportive care.

Grade 3 or higher (increase of 7 stools or more per day over baseline; hospitalization indicated)Any

Interrupt
Xpovio and institute supportive care.
Monitor until diarrhea resolves to Grade 2 or lower.
Restart
Xpovio at 1 dose level lower (see Table 1).

Weight Loss and Anorexia Weight loss of 10% to less than 20%
OR
Anorexia associated with significant weight loss or malnutritionAny

Interrupt
Xpovio and institute supportive care.
Monitor until weight returns to more than 90% of baseline weight.
Restart
Xpovio at 1 dose level lower (see Table 1).

Hyponatremia Sodium level 130 mmol/L or lessAny

Interrupt
Xpovio, evaluate, and provide supportive care.
Monitor until sodium levels return to greater than 130 mmol/L.
Restart
Xpovio at 1 dose level lower (see Table 1).

FatigueGrade 2 lasting greater than 7 days
OR
Grade 3Any

Interrupt
Xpovio.
Monitor until fatigue resolves to Grade 1 or baseline.
Restart
Xpovio at 1 dose level lower (see Table 1).

Ocular Toxicity Grade 2, excluding cataractAny

Perform ophthalmologic evaluation.
Interrupt
Xpovio and provide supportive care.
Monitor until ocular symptoms resolve to Grade 1 or baseline.
Restart
Xpovio at 1 dose level lower (see Table 1).

Grade ≥3, excluding cataractAny

Permanently discontinue
Xpovio.
Perform ophthalmologic evaluation.

Other Non-Hematologic Adverse ReactionsGrade 3 or 4Any

Interrupt
Xpovio.
Monitor until resolved to Grade 2 or lower; restart Xpovio at 1 dose level lower (see Table 1).

Administration

Each Xpovio dose should be taken at approximately the same time of day and each tablet should be swallowed whole with water. Do not break, chew, crush, or divide the tablets.
If a dose of Xpovio is missed or delayed, instruct patients to take their next dose at the next regularly scheduled time.
If a patient vomits a dose of Xpovio, the patient should not repeat the dose and the patient should take the next dose on the next regularly scheduled day.

What drugs interact with Xpovio?

No Information Provided

Is Xpovio safe to use while pregnant or breastfeeding?

Based on findings in animal studies and its mechanism of action, Xpovio can cause fetal harm when administered to a pregnant woman.
There are no available data in pregnant women to inform the drug-associated risk.
There is no information regarding the presence of selinexor or its metabolites in human milk, or their effects on the breastfed child or milk production.
Because of the potential for serious adverse reactions in a breastfed
child, women should not breastfeed during treatment with Xpovio and for 1 week after the last dose.

Signs of Cancer: Symptoms, Causes, Types, Treatment & Stages

Cancer facts

Cancer comes from overproduction and malfunction of the body's own cells.

Cancer is the uncontrolled growth of abnormal cells anywhere in a body.
There are over 200 types of cancer.
Anything that may cause a normal body cell to develop abnormally potentially can cause cancer; general categories of cancer-related or causative agents are as follows: chemical or toxic compound exposures, ionizing radiation, some pathogens, and human genetics.
Cancer symptoms and signs depend on the specific type and grade of cancer; although general signs and symptoms are not very specific the following can be found in patients with different cancers: fatigue, weight loss, pain, skin changes, change in bowel or bladder function, unusual bleeding, persistent cough or voice change, fever, lumps, or tissue masses.
Although there are many tests to screen and presumptively diagnose cancer, the definite diagnosis is made by examination of a biopsy sample of suspected cancer tissue.
Cancer staging is often determined by biopsy results and helps determine the cancer type and the extent of cancer spread; staging also helps caregivers determine treatment protocols. In general, in most staging methods, the higher the number assigned (usually between 0 to 4), the more aggressive the cancer type or the more widespread is cancer in the body. Staging methods differ from cancer to cancer and need to be individually discussed with your health care provider.
Treatment protocols vary according to the type and stage of cancer. Most treatment protocols are designed to fit the individual patient's disease. However, most treatments include at least one of the following and may include all: surgery, chemotherapy, and radiation therapy.
There are many listed home remedies and alternative treatments for cancers but patients are strongly recommended to discuss these before use with their cancer doctors.
The prognosis of cancer can range from excellent to poor. The prognosis depends on the cancer type and its staging with those cancers known to be aggressive and those staged with higher numbers (3 to 4) often have a prognosis that ranges more toward poor.

What Is Cancer & What Causes It?

When cells become cancerous

In the most basic terms, cancer refers to cells that grow out-of-control and invade other tissues. Cells become cancerous due to the accumulation of defects, or mutations, in their DNA. Certain:

inherited genetic defects (for example, BRCA1 and BRCA2 mutations),
infections,
environmental factors (for example, air pollution), and
poor lifestyle choices — such as smoking and heavy alcohol use — can also damage DNA and lead to cancer.

Most of the time, cells are able to detect and repair DNA damage. If a cell is severely damaged and cannot repair itself it undergoes so-called programmed cell death or apoptosis. Cancer occurs when damaged cells grow, divide, and spread abnormally instead of self-destructing as they should.

What is cancer?

These abnormal cells are termed cancer cells, malignant cells, or tumor cells. These cells can infiltrate normal body tissues.

Cancer is the uncontrolled growth of abnormal cells anywhere in a body. These abnormal cells are termed cancer cells, malignant cells, or tumor cells. These cells can infiltrate normal body tissues. Many cancers and the abnormal cells that compose the cancer tissue are further identified by the name of the tissue that the abnormal cells originated from (for example, breast cancer, lung cancer, colorectal cancer). Cancer is not confined to humans; animals and other living organisms can get cancer. Below is a schematic that shows normal cell division and how when a cell is damaged or altered without repair to its system, the cell usually dies. Also shown is what occurs when such damaged or unrepaired cells do not die and become cancer cells and show uncontrolled division and growth — a mass of cancer cells develop. Frequently, cancer cells can break away from this original mass of cells, travel through the blood and lymph systems, and lodge in other organs where they can again repeat the uncontrolled growth cycle. This process of cancer cells leaving an area and growing in another body area is termed metastatic spread or metastasis. For example, if breast cancer cells spread to a bone, it means that the individual has metastatic breast cancer to bone. This is not the same as "bone cancer," which would mean cancer had started in the bone.

The following table (National Cancer Institute 2016) gives the estimated numbers of new cases and deaths for each common cancer type:

Cancer Type Estimated New Cases Estimated Deaths

Bladder
76,960
16,390

Breast (Female — Male)
246,660 — 2,600
40,450 — 440

Colorectal Cancer
134,490
49,190

Endometrial
60,050
10,470

Kidney (Renal Cell and Renal Pelvis) Cancer
62,700
14,240

Leukemia (All Types)
60,140
24,400

Lung (Including Bronchus)
224,390
158,080

Melanoma
76,380
10,130

Non-Hodgkin Lymphoma
72,580
20,150

Pancreatic
53,070
41,780

Prostate
180,890
26,120

Thyroid
64,300
1,980

The three most common cancers in men, women, and children in the U.S. are as follows:

Men: Prostate, lung, and colorectal
Women: Breast, lung, and colorectal
Children: Leukemia, brain tumors, and lymphoma

The incidence of cancer and cancer types are influenced by many factors such as age, gender, race, local environmental factors, diet, and genetics. Consequently, the incidence of cancer and cancer types vary depending on these variable factors. For example, the World Health Organization (WHO) provides the following general information about cancer worldwide:

Cancer is a leading cause of death worldwide. It accounted for 8.2 million deaths (around 22% of all deaths not related to communicable diseases; most recent data from WHO).
Lung, stomach, liver, colon, and breast cancer cause the most cancer deaths each year.
Deaths from cancer worldwide are projected to continue rising, with an estimated 13.1 million deaths in 2030 (about a 70% increase).

Different areas of the world may have cancers that are either more or less predominant than those found in the U.S. One example is that stomach cancer is often found in Japan, while it is rarely found in the U.S. This usually represents a combination of environmental and genetic factors.

The objective of this article is to introduce the reader to general aspects of cancers. It is designed to be an overview of cancer and cannot cover every cancer type. This article will also attempt to help guide the reader to more detailed sources about specific cancer types.

What are risk factors and causes of cancer?

Tobacco or cigarette smoke contains at least 66 known potential carcinogenic chemicals and toxins.

Anything that may cause a normal body cell to develop abnormally potentially can cause cancer. Many things can cause cell abnormalities and have been linked to cancer development. Some cancer causes remain unknown while other cancers have environmental or lifestyle triggers or may develop from more than one known cause. Some may be developmentally influenced by a person's genetic makeup. Many patients develop cancer due to a combination of these factors. Although it is often difficult or impossible to determine the initiating event(s) that cause cancer to develop in a specific person, research has provided clinicians with a number of likely causes that alone or in concert with other causes, are the likely candidates for initiating cancer. The following is a listing of major causes and is not all-inclusive as specific causes are routinely added as research advances:

Chemical or toxic compound exposures: Benzene, asbestos, nickel, cadmium, vinyl chloride, benzidine, N-nitrosamines, tobacco or cigarette smoke (contains at least 66 known potential carcinogenic chemicals and toxins), asbestos, and aflatoxin

Ionizing radiation: Uranium, radon, ultraviolet rays from sunlight, radiation from alpha, beta, gamma, and X-ray-emitting sources

Pathogens: Human papillomavirus (HPV), EBV or Epstein-Barr virus, hepatitis viruses B and C, Kaposi's sarcoma-associated herpes virus (KSHV), Merkel cell polyomavirus, Schistosoma spp., and Helicobacter pylori; other bacteria are being researched as possible agents.

Genetics: A number of specific cancers have been linked to human genes and are as follows: breast, ovarian, colorectal, prostate, skin, and melanoma; the specific genes and other details are beyond the scope of this general article so the reader is referred to the National Cancer Institute for more details about genetics and cancer.

It is important to point out that most everyone has risk factors for cancer and is exposed to cancer-causing substances (for example, sunlight, secondary cigarette smoke, and X-rays) during their lifetime, but many individuals do not develop cancer. In addition, many people have genes that are linked to cancer but do not develop it. Why? Although researchers may not be able to give a satisfactory answer for every individual, it is clear that the higher the amount or level of cancer-causing materials a person is exposed to, the higher the chance the person will develop cancer. In addition, people with genetic links to cancer may not develop it for similar reasons (lack of enough stimulus to make the genes function). In addition, some people may have a heightened immune response that controls or eliminates cells that are or potentially may become cancer cells. There is evidence that even certain dietary lifestyles may play a significant role in conjunction with the immune system to allow or prevent cancer cell survival. For these reasons, it is difficult to assign a specific cause of cancer to many individuals.

Recently, other risk factors have been added to the list of items that may increase cancer risk. Specifically, red meat (such as beef, lamb, and pork) was classified by the International Agency for Research on Cancer as a high-risk agent for potentially causing cancers; in addition processed meats (salted, smoked, preserved, and/or cured meats) were placed on the carcinogenic list. Individuals that eat a lot of barbecued meat may also increase risk due to compounds formed at high temperatures. Other less defined situations that may increase the risk of certain cancers include obesity, lack of exercise, chronic inflammation, and hormones, especially those hormones used for replacement therapy. Other items such as cell phones have been heavily studied. In 2011, the World Health Organization classified cell phone low energy radiation as "possibly carcinogenic," but this is a very low-risk level that puts cell phones at the same risk as caffeine and pickled vegetables.

Proving that a substance does not cause or is not related to increased cancer risk is difficult. For example, antiperspirants are considered to possibly be related to breast cancer by some investigators and not by others. The official stance by the NCI is "additional research is needed to investigate this relationship and other factors that may be involved." This unsatisfying conclusion is presented because the data collected so far is contradictory. Other claims that are similar require intense and expensive research that may never be done. Reasonable advice might be to avoid large amounts of any compounds even remotely linked to cancer, although it may be difficult to do in complex, technologically advanced modern societies.

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What are cancer symptoms and signs?

Symptoms and signs of cancer depend on the type of cancer, where it is located, and/or where the cancer cells have spread. For example, breast cancer may present as a lump in the breast or as nipple discharge while metastatic breast cancer may present with symptoms of pain (if spread to bones), extreme fatigue (lungs), or seizures (brain). A few patients show no signs or symptoms until the cancer is far advanced.

The American Cancer Society describes seven warning signs and/or symptoms that cancer may be present, and which should prompt a person to seek medical attention. The word CAUTION can help you remember these.

Change in bowel or bladder habits
A sore throat that does not heal
Unusual bleeding or discharge (for example, nipple secretions or a "sore" that will not heal that oozes material)
Thickening or lump in the breast, testicles, or elsewhere
Indigestion (usually chronic) or difficulty swallowing
Obvious change in the size, color, shape, or thickness of a wart or mole
Nagging cough or hoarseness

Other signs or symptoms may also alert you or your doctor to the possibility of your having some form of cancer. These include the following:

Unexplained loss of weight or loss of appetite
A new type of pain in the bones or other parts of the body that may be steadily worsening, or come and go, but is unlike previous pains one has had before
Persistent fatigue, nausea, or vomiting
Unexplained low-grade fevers may be either persistent or come and go
Recurring infections which will not clear with usual treatment

Anyone with these signs and symptoms should consult their doctor; these symptoms may also arise from noncancerous conditions.

Many cancers will present with some of the above general symptoms but often have one or more symptoms that are more specific for the cancer type. For example, lung cancer may present with common symptoms of pain, but usually, the pain is located in the chest. The patient may have unusual bleeding, but the bleeding usually occurs when the patient coughs. Lung cancer patients often become short of breath and then become very fatigued.

Because there are so many cancer types (see next section) with so many nonspecific and sometimes more specific symptoms, the best way to learn about signs and symptoms of specific cancer types is to spend a few moments researching symptoms of a specific body area in question. Conversely, a specific body area can be searched to discover what signs and symptoms a person should look for in that area that is suspected of having cancer. The following examples are two ways to proceed to get information on symptoms:

Use a search engine (Google, Bing) to find links to cancer by listing the symptom followed by the term "cancer" or if you know the type you want information about, (lung, brain, breast) use MedicineNet’s search option. For example, listing "blood in urine and cancer" will bring a person to websites that list possible organs and body systems where cancer may produce the listed symptoms.
Use a search engine as above and list the suspected body area and cancer (for example, bladder, and cancer), and the person will see sites that list the signs and symptoms of cancer in that area (blood in urine is one of several symptoms listed).
Be aware that many websites are not necessarily reviewed by a health care professional and could contain information that is not accurate. Your health care professional is ultimately the best resource if you have concerns.

Besides, if the cancer type is known (diagnosed), then even more specific searches can be done listing the diagnosed cancer type and whatever may be questioned about cancer (symptoms, tumor grades, treatments, prognosis, and many other items).

One's own research should not replace consulting a health care provider if someone is concerned about cancer.

QUESTION

Cancer is the result of the uncontrolled growth of abnormal cells anywhere in the body.
See Answer

What are the different types of cancer?

There are over 200 types of cancer; far too numerous to include in this introductory article. However, the NCI lists several general categories (see list in first section of this article). This list is expanded below to list more specific types of cancers found in each general category; it is not all inclusive and the cancers listed in quotes are the general names of some cancers:

Carcinoma: Cancer that begins in the skin or in tissues that line or cover internal organs — "skin, lung, colon, pancreatic, ovarian cancers," epithelial, squamous and basal cell carcinomas, melanomas, papillomas, and adenomas
Sarcoma: Cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue — "bone, soft tissue cancers," osteosarcoma, synovial sarcoma, liposarcoma, angiosarcoma, rhabdosarcoma, and fibrosarcoma
Leukemia: Cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood — "leukemia," lymphoblastic leukemias (ALL and CLL), myelogenous leukemias (AML and CML), T-cell leukemia, and hairy-cell leukemia
Lymphoma and myeloma: Cancers that begin in the cells of the immune system — "lymphoma," T-cell lymphomas, B-cell lymphomas, Hodgkin lymphomas, non-Hodgkin lymphoma, and lymphoproliferative lymphomas
Central nervous system cancers: Cancers that begin in the tissues of the brain and spinal cord — "brain and spinal cord tumors," gliomas, meningiomas, pituitary adenomas, vestibular schwannomas, primary CNS lymphomas, and primitive neuroectodermal tumors

Not included in the above types listed are metastatic cancers; this is because metastatic cancer cells usually arise from a cell type listed above and the major difference from the above types is that these cells are now present in a tissue from which the cancer cells did not originally develop. Consequently, if the terms "metastatic cancer" is used, for accuracy, the tissue from which the cancer cells arose should be included. For example, a patient may say they have or are diagnosed with "metastatic cancer" but the more accurate statement is "metastatic (breast, lung, colon, or other type) cancer with spread to the organ in which it has been found." Another example is the following: A doctor describing a man whose prostate cancer has spread to his bones should say the man has metastatic prostate cancer to bone. This is not "bone cancer," which would be cancer that started in the bone cells. Metastatic prostate cancer to bone is treated differently than lung cancer to bone.

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What specialists treat cancer?

A doctor who specializes in the treatment of cancer is called an oncologist. He or she may be a surgeon, a specialist in radiation therapy, or a medical oncologist. The first uses surgery to treat the cancer; the second, radiation therapy; the third, chemotherapy and related treatments. Each may consult with the others to develop a treatment plan for the particular patient.

In addition, other specialists may be involved depending upon where the cancer is located. For example, ob-gyn specialists may be involved with uterine cancer while an immunologist maybe involved in treatment of cancers that occur in the immune system. Your primary care physician and main oncologist will help you to determine what specialists are best to be members of your treatment team.

How do health care professionals diagnose cancer?

Some cancers are diagnosed during routine screening examinations. These usually test that is routinely done at a certain age. Many cancers are discovered when you present to your health care professional with specific symptoms.

A physical exam and medical history, especially the history of symptoms, are the first steps in diagnosing cancer. In many instances, the medical caregiver will order several tests, most of which will be determined by the type of cancer and where it is suspected to be located in or on the person's body. Also, most caregivers will order a complete blood count, electrolyte levels, and, in some cases, other blood studies that may give additional information.

Imaging studies are commonly used to help physicians detect abnormalities in the body that may be cancer. X-rays, CT and MRI scans, and ultrasound are common tools used to examine the body. Other tests such as endoscopy, which with variations in the equipment used, can allow visualization of tissues in the intestinal tract, throat, and bronchi that may be cancerous. In areas that cannot be well visualized (inside bones or some lymph nodes, for example), radionuclide scanning is often used. The test involves ingestion or IV injection of a weakly radioactive substance that can be concentrated and detected in the abnormal tissue.

The preceding tests can be very good at localizing abnormalities in the body; many clinicians consider that some of the tests provide presumptive evidence for the diagnosis of cancer. However, in virtually all patients, the definitive diagnosis of cancer is based on the examination of a tissue sample taken in a procedure called a biopsy from the tissue that may be cancerous and then analyzed by a pathologist. Some biopsy samples are relatively simple to procure (for example, a skin biopsy or intestinal tissue biopsy done with a device called an endoscope equipped with a biopsy attachment). Other biopsies may require as little as a carefully guided needle, or as much as a surgery (for example, brain tissue or lymph node biopsy). In some instances, the surgery to diagnose cancer may result in a cure if all of the cancerous tissue is removed at the time of biopsy.

The biopsy can provide more than the definitive diagnosis of cancer; it can identify the cancer type (for example, the type of tissue found may indicate that the sample is from a primary [started here] or metastatic type of brain cancer [spread from another primary tumor arising elsewhere in the body] and thereby help to stage cancer. The stage, or cancer staging, is a way for clinicians and researchers to estimate how extensive the cancer is in the patient's body.

Is cancer that has been found localized to its site of origin, or is it spread from that site to other tissues? Localized cancer is said to be at an early stage, while one which has spread is at an advanced stage. The following section describes the general staging methods for cancers.

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How do physicians determine cancer staging?

There are a number of different staging methods used for cancers and the specific staging criteria varies among cancer types. According to the NCI, the common elements considered in most staging systems are as follows:

Site of the primary tumor
Tumor size and number of tumors
Lymph node involvement (spread of cancer into lymph nodes)
Cell type and tumor grade (how closely the cancer cells resemble normal tissue cells)
The presence or absence of metastasis

However, there are two main methods that form the basis for the more specific or individual cancer type staging. The TMN staging is used for most solid tumors while the Roman numeral or stage grouping method is used by some clinicians and researchers on almost all cancer types.

The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of distant metastasis (M). A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread (higher number means bigger tumor or more spread).

The following is how the NCI describes the TNM staging system:

Primary tumor (T)
- TX – Primary tumor cannot be evaluated
- T0 – No evidence of primary tumor
- Tis – Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called pre-invasive cancer)
- T1, T2, T3, T4 – Size and/or extent of the primary tumor
Regional lymph nodes (N)
- NX – Regional lymph nodes cannot be evaluated
- N0 – No regional lymph node involvement
- N1, N2, N3 – Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)
Distant metastasis (M)
- MX – Distant metastasis cannot be evaluated (some clinicians do not ever use this designation)
- M0 – No distant metastasis
- M1 – Distant metastasis is present

Consequently, a person's cancer could be listed as T1N2M0, meaning it is a small tumor (T1), but has spread to some regional lymph nodes (N2), and has no distant metastasis (M0).

The Roman numeral or stage grouping method is described by the NCI as follows:

Stage Definition Stage 0Carcinoma in situ.Stage IHigher numbers indicate more extensive disease: Larger tumor size and/or spread of the cancer beyond the organ in which it first developed to nearby lymph nodes and/or organs adjacent to the location of the primary tumorStage IIStage IIIStage IVThe cancer has spread to another organ(s).

As mentioned above, variations of these staging methods exist. For example, some cancer registries use surveillance, epidemiology, and end results program (SEER) termed summary staging. SEER groups cancer cases into five main categories:

In situ: Abnormal cells are present only in the layer of cells in which they developed.
Localized: Cancer is limited to the organ in which it began, without evidence of spread.
Regional: Cancer has spread beyond the primary site to nearby lymph nodes or organs and tissues.
Distant: Cancer has spread from the primary site to distant organs or distant lymph nodes.
Unknown: There is not enough information to determine the stage.

Staging of cancer is important; it helps the physician to decide on the most effective therapeutic protocols, provides a basis for estimating the prognosis (outcome) for the patient, and provides a system to communicate the patient's condition to other health professionals that become involved with the patients' care.

What are cancer treatment options?

The cancer treatment is based on the type of cancer and the stage of the cancer. In some people, diagnosis and treatment may occur at the same time if the cancer is entirely surgically removed when the surgeon removes the tissue for biopsy.

Although patients may receive a unique sequenced treatment, or protocol, for their cancer, most treatments have one or more of the following components: surgery, chemotherapy, radiation therapy, or combination treatments (a combination of two or all three treatments).

Individuals obtain variations of these treatments for cancer. Patients with cancers that cannot be cured (completely removed) by surgery usually will get combination therapy, the composition determined by the cancer type and stage.

Palliative therapy (medical care or treatment used to reduce disease symptoms but unable to cure the patient) utilizes the same treatments described above. It is done with the intent to extend and improve the quality of life of the terminally ill cancer patient. There are many other palliative treatments to reduce symptoms such as pain medications and antinausea medications.

Are there home remedies or alternative treatments for cancer?

There are many claims on the Internet and in publications about substances that treat cancer (for example, broccoli, grapes, ginseng, soybeans, green tea, aloe vera, and lycopene and treatments like acupuncture, vitamins, and dietary supplements). Almost every physician suggests that a balanced diet and good nutrition will help an individual combat cancer. Although some of these treatments may help reduce symptoms, there is no good evidence they can cure any cancers. Patients are strongly recommended to discuss any home remedies or alternative treatments with their cancer doctors before beginning any of these.

What is the prognosis for cancer?

The prognosis (outcome) for cancer patients may range from excellent to poor. The prognosis is directly related to both the type and stage of the cancer. For example, many skin cancers can be completely cured by removing the skin cancer tissue; similarly, even a patient with a large tumor may be cured after surgery and other treatments like chemotherapy (note that a cure is often defined by many clinicians as a five-year period with no reoccurrence of the cancer). However, as the cancer type either is or becomes aggressive, with spread to lymph nodes or is metastatic to other organs, the prognosis decreases. For example, cancers that have higher numbers in their staging (for example, stage III or T3N2M1; see staging section above) have a worse prognosis than those with low (or 0) numbers. As the staging numbers increase, the prognosis worsens and the survival rate decreases.

This article offers a general introduction to cancers, consequently the details — such as life expectancy for each cancer — cannot be covered. However, cancers in general have a decreasing life expectancy as the stage of the cancer increases. Depending on the type of the cancer, as the prognosis decreases, so does life expectancy. On the positive side, cancers that are treated and do not recur (no remissions) within a five-year period in general suggest that the patient will have a normal life expectancy. Some patients will be cured, and a few others may get recurrent cancer. Unfortunately, there are no guarantees.

There are many complications that may occur with cancer; many are specific to the cancer type and stage and are too numerous to list here. However, some general complications that may occur with both cancer and its treatment protocols are listed below:

Fatigue (both due to cancer and its treatments)
Anemia (both)
Loss of appetite (both)
Insomnia (both)
Hair loss (treatments mainly)
Nausea (both)
Lymphedema (both)
Pain (both)
Immune system depression (both)

Is it possible to prevent cancer?

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Most experts are convinced that many cancers can either be prevented or the risk of developing cancers can be markedly reduced. Some of the cancer prevention methods are simple; others are relatively extreme, depending on an individual's view.

Cancer prevention, by avoiding its potential causes, is the simplest method. First on most clinicians and researchers list is to stop (or better, never start) smoking tobacco. Avoiding excess sunlight (by decreasing exposure or applying sunscreen) and many of the chemicals and toxins are excellent ways to avoid cancers. Avoiding contact with certain viruses and other pathogens also are likely to prevent some cancers. People who have to work close to cancer-causing agents (chemical workers, X-ray technicians, ionizing radiation researchers, asbestos workers) should follow all safety precautions and minimize any exposure to such compounds. Although the FDA and the CDC suggests that there is no scientific evidence that definitively says cell phones cause cancer, other agencies call for more research or indicate the risk is very low. Individuals who are concerned can limit exposure to cell phones by using an earpiece and simply make as few cell phone calls as possible.

There are two vaccines currently approved by the U.S. Food and Drug Administration (FDA) to prevent specific types of cancer. Vaccines against the hepatitis B virus, which is considered a cause of some liver cancers, and vaccines against human papillomavirus (HPV) types 16 and 18 are available. According to the NCI, these viruses are responsible for about 70% of cervical cancers. These virus also plays a role in cancers arising in the head and neck, as well as cancers in the anal region, and probably in others. Today, vaccination against HPV is recommended in teenagers and young adults of both sexes. The HPV virus is so common that by the age of 50, half or more people have evidence of being exposed to it. Sipuleucel-T is a new vaccine approved by the FDA to help treat advanced prostate cancer. Although vaccine does not cure prostate cancer, it has been shown to help extend the lifespan of individuals with advanced prostate cancer.

People with a genetic predisposition to develop certain cancers and others with a history of cancers in their genetically linked relatives currently cannot change their genetic makeup. However, some individuals who have a high possibility of developing genetically linked cancer have taken actions to prevent cancer development. For example, some young women who have had many family members develop breast cancer have elected to have their breast tissue removed even if they have no symptoms or signs of cancer development to reduce or eliminate the possibility they will develop breast cancer. Some doctors consider this as an extreme measure to prevent cancer while others do not.

Screening tests and studies for cancer are meant to help detect a cancer at an early stage when the cancer is more likely to be potentially cured with treatment. Such screening studies are breast exams, testicular exams, colon-rectal exams (colonoscopy), mammography, certain blood tests, prostate exams, urine tests and others. People who have any suspicion that they may have cancer should discuss their concerns with their doctor as soon as possible. Screening recommendations have been the subject of numerous conflicting reports in recent years. Screening may not be cost effective for many groups of patients or lead to unnecessary further invasive tests, but individual patients' unique circumstances should always be considered by doctors in making recommendations about ordering or not ordering screening tests.

Where can people find more information about cancer?

There are many ways a person can find more information about cancer, but if they have any immediate concerns about having cancer, their first source of information should be their doctor. In addition to the references listed at the end of this article, the following is a list of information sources that are well recognized as authorities for cancer information by most clinicians:

American Cancer Society (http://www.cancer.org/Cancer/index)
National Cancer Institute (http://www.cancer.gov/)

Bile Duct Cancer: Symptoms, Treatment, Life Expectancy, Causes & Stages

Facts you should know about bile duct cancer (cholangiocarcinoma)

Bile duct cancers are most commonly found just outside of the liver in the perihilar area and least commonly found within the liver.

Bile duct cancer arises from the cells that line the bile ducts, the drainage system for bile that is produced by the liver. Bile ducts collect this bile, draining it into the gallbladder and finally into the small intestine where it aids in the digestion process. Bile duct cancer is also called cholangiocarcinoma.

Bile duct cancer is a rare form of cancer, with approximately 2,500 new cases diagnosed in the United States each year. There are three general locations where this type of cancer may arise within the bile drainage system:

Within the liver (intrahepatic) affecting the bile ducts located within the liver
Just outside of the liver (extrahepatic or perihilar) located at the notch of the liver where the bile ducts exit
Far outside of the liver (distal extrahepatic) near where the bile ducts enter the intestine (called the ampulla of Vater)

Bile duct cancers are most commonly found just outside of the liver in the perihilar area and least commonly found within the liver.

Sign of Bile Duct Cancer

Jaundice

Jaundice, also referred to as icterus, is the yellow staining of the skin and sclerae (the whites of the eyes) by abnormally high blood levels of the bile pigment, bilirubin. The yellowing extends to other tissues and body fluids and also may turn the urine dark. Yellowing of only the skin also can be caused by eating too many carrots or drinking too much carrot juice.

Jaundice can occur whenever this normal process of destruction of red blood cells and elimination of bilirubin is interrupted. This occurs when there is abnormally increased destruction of red blood cells (hemolysis), liver disease that reduces the ability of the liver to remove and modify bilirubin, or obstruction to the flow of bile into the intestine.

What are causes and risk factors for bile duct cancer?

Depending upon where the bile duct blockage occurs, this can lead to inflammation of the liver (hepatitis) and/or pancreas (pancreatitis).

The incidence of bile duct cancer increases with age. It is slow-growing cancer that invades local structures and for that reason, the diagnosis is often made late in the disease process when the bile ducts become blocked. This blockade prevents bile drainage from the liver into the gallbladder and intestine. Depending upon where the blockage occurs, this can lead to inflammation of the liver (hepatitis) and/or pancreas (pancreatitis).

Most patients who develop bile duct cancer have no risk to do so. However, chronic inflammation of the bile ducts may be a risk factor for this cancer. Diseases that can cause this type of chronic inflammation include primary sclerosing cholangitis (especially when associated with ulcerative colitis), chronic liver disease, including hepatitis B, hepatitis C, chronic alcoholic hepatitis, and cirrhosis.

Certain parasitic infections found in the Far East that cause liver infections are associated with an increased risk.

Gallstones are not a risk factor for developing bile duct cancer, but stones within the liver do pose an increased risk. Liver stones are not often seen in the North American population but are more common in Asian countries.

There are rare congenital diseases that increase the risk of bile duct cancer, including Lynch II syndrome (hereditary nonpolyposis colorectal cancer associated with biliary tree and other cancers) and Caroli's syndrome (portal hypertension, hepatic fibrosis, and biliary tree cysts).

Native Americans are six times more likely to develop bile duct cancer. Asian Americans may also be at higher risk. Bile duct cancer is also more prevalent in Israel and Japan, but it is a very rare disease in North America.

What are bile duct cancer symptoms and signs?

The initial symptoms of bile duct cancer are jaundice, itching, abdominal pain, bloating, and weight loss.

The initial symptoms of bile duct cancer occur because of the inability of bile to drain normally from the liver where it is produced. This causes liver inflammation (hepatitis). Cholangiocarcinoma symptoms include yellow coloring of the skin and eyes (jaundice), itching, abdominal pain, bloating, and weight loss. Low-grade fever may be present, and there can be darkening in the color of urine and stool.

Unfortunately, bile duct tumors may not cause any symptoms until they have grown in size and cancer has spread (metastasized) from beyond its original location. Abdominal pain is often a late symptom and is usually located in the right upper quadrant of the belly and may be associated with a tender, enlarged liver.