Persistent Fatigue In Disease Free Breast Cancer Survivors

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Persistent Fatigue in Disease-free Breast Cancer Survivors

Author : Monica Elissa Lindgren
Publisher :
ISBN 13 :
Total Pages : 139 pages
Book Rating : 4.:/5 (967 download)

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Book Synopsis Persistent Fatigue in Disease-free Breast Cancer Survivors by : Monica Elissa Lindgren

Download or read book Persistent Fatigue in Disease-free Breast Cancer Survivors written by Monica Elissa Lindgren and published by . This book was released on 2016 with total page 139 pages. Available in PDF, EPUB and Kindle. Book excerpt: Breast cancer survivors with histories of depression experience heightened fatigue long after treatment. The mechanisms by which prior depression influences persistent post-treatment fatigue are not fully understood; however, psychological processes are hypothesized to influence this relationship. This study investigated how cancer-specific avoidance, a coping strategy whereby survivors intentionally deny and avoid negative thoughts and emotions about cancer, may explain this association. Further, the study tested if past depression’s indirect effects on fatigue (through avoidance coping) intensified when women also experienced more severe physical symptoms during treatment. Effects of pretreatment depression histories on survivors’ fatigue trajectories from diagnosis to 18-months after treatment were also examined. Women with newly-diagnosed breast cancer (N = 209) were followed across three time points, at diagnosis, then 6-months and 18-months post-treatment. At each assessment, women completed self-report questionnaires, including the Multidimensional Fatigue Symptom Inventory-Short Form to measure fatigue, the Impact of Events Scale to measure avoidance coping, and the Center for Epidemiological Depression Scale to measure concurrent depressive symptoms. Depression before treatment was assessed via a clinical interview. Severity of physical symptoms during treatment were collected from medical records and measured as: (1) number of acute treatment side-effects and toxicities, and (2) nurse-assessed, objective ratings of patients’ physical disability (performance status scores). Hierarchical linear growth modeling was used to examine the shape of survivors’ fatigue trajectories over time. Moderated mediation was used to examine whether greater post-treatment avoidance coping explained associations between pretreatment depression and post-treatment fatigue, conditioned upon severity of survivors’ physical symptoms during treatment. Analyses controlled for factors with previously-established relationships to persistent cancer-related fatigue. As expected, previously-depressed women’s fatigue did not decline as much as never-depressed women’s fatigue across assessments. However, there was no evidence that greater avoidance coping, even when following more severe physical symptoms during treatment, explained associations between pretreatment depression histories and post-treatment fatigue levels. Findings suggest early fatigue interventions for patients with pretreatment depression may prevent persistently elevated fatigue in the 18-months following treatment. Results also suggest cognitive-behavioral treatment models for cancer-related fatigue, which focus on correcting dysfunctional coping strategies like cancer-specific avoidance, may have limited therapeutic relevance for breast cancer survivors with pretreatment depression histories.

Interventions to Address Persistent Fatigue in Breast Cancer Survivors

Author : Susan E. Appling
Publisher :
ISBN 13 :
Total Pages : 208 pages
Book Rating : 4.:/5 (88 download)

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Book Synopsis Interventions to Address Persistent Fatigue in Breast Cancer Survivors by : Susan E. Appling

Download or read book Interventions to Address Persistent Fatigue in Breast Cancer Survivors written by Susan E. Appling and published by . This book was released on 2011 with total page 208 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Cognitive-Behavioral Stress Management

Author : Michael H. Antoni
Publisher : Oxford University Press
ISBN 13 : 0190450029
Total Pages : 144 pages
Book Rating : 4.1/5 (94 download)

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Book Synopsis Cognitive-Behavioral Stress Management by : Michael H. Antoni

Download or read book Cognitive-Behavioral Stress Management written by Michael H. Antoni and published by Oxford University Press. This book was released on 2007-09-10 with total page 144 pages. Available in PDF, EPUB and Kindle. Book excerpt: Living with HIV can be stressful, which can affect both your emotional and physical well-being. You may feel a loss of control over your life, socially isolated, or anxious and depressed. Studies have shown that prolonged stress can negatively impact the immune system, making it less effective in fighting illness. If you are concerned about the impact stress has on your life and on your health, this book can help you learn to relax and manage stress more effectively. This book presents a group treatment program that has been scientifically proven to reduce stress in individuals living with HIV. Written by the developers of this groundbreaking program, this workbook is based on the principles of Cognitive-Behavioral Stress Management (CBSM). You will learn a variety of relaxation techniques, all designed to help you reduce tension and stress. As you become more aware of stress and its effects, stress management skills will increase your ability to cope. This workbook comes complete with user-friendly monitoring forms and homework exercises designed to help reinforce the skills learned in group. It also includes instructions for relaxation practice that will remain useful long after you've completed the program. Used in conjunction with the group program described in the corresponding facilitator guide, this workbook will help you successfully manage stress and lead a more healthy life. TreatmentsThatWorkTM represents the gold standard of behavioral healthcare interventions! · All programs have been rigorously tested in clinical trials and are backed by years of research · A prestigious scientific advisory board, led by series Editor-In-Chief David H. Barlow, reviews and evaluates each intervention to ensure that it meets the highest standard of evidence so you can be confident that you are using the most effective treatment available to date · Our books are reliable and effective and make it easy for you to provide your clients with the best care available · Our corresponding workbooks contain psychoeducational information, forms and worksheets, and homework assignments to keep clients engaged and motivated · A companion website (www.oup.com/us/ttw) offers downloadable clinical tools and helpful resources · Continuing Education (CE) Credits are now available on select titles in collaboration with PsychoEducational Resources, Inc. (PER)

Fatigue in Cancer

Author : Maryl Lynne Winningham
Publisher : Jones & Bartlett Learning
ISBN 13 : 9780763706302
Total Pages : 470 pages
Book Rating : 4.7/5 (63 download)

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Book Synopsis Fatigue in Cancer by : Maryl Lynne Winningham

Download or read book Fatigue in Cancer written by Maryl Lynne Winningham and published by Jones & Bartlett Learning. This book was released on 2000 with total page 470 pages. Available in PDF, EPUB and Kindle. Book excerpt: The study of fatigue as a major focus in clinical practice and research is relatively new, but the editors argue that much more is known about it than most texts admit. Here two dozen essays and interviews represent the perspectives of clinically oriented people, who often go beyond the established

Post-treatment Fatigue in Breast Cancer Survivors

Author : Rajni Banthia
Publisher :
ISBN 13 :
Total Pages : 238 pages
Book Rating : 4.:/5 (318 download)

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Book Synopsis Post-treatment Fatigue in Breast Cancer Survivors by : Rajni Banthia

Download or read book Post-treatment Fatigue in Breast Cancer Survivors written by Rajni Banthia and published by . This book was released on 2004 with total page 238 pages. Available in PDF, EPUB and Kindle. Book excerpt: The majority of women with breast cancer experience persistent fatigue during or following treatment. The present study contributes to the understanding of post-treatment breast cancer-related fatigue by exploring the relationship to fatigue of psychosocial factors such as depressed mood and sleep quality. Seventy breast cancer survivors who were between one month and three years post-treatment for breast cancer, and who were reporting clinically elevated levels of general fatigue, were asked to complete the Multidimensional Fatigue Symptom Inventory, Center for Epidemiological Studies-Depression Scale, and Pittsburgh Sleep Quality Index. Discriminant function analyses were employed to predict fatigue subgroup membership (high, low on five subscales) from the following variables: age, stage of cancer, depressed mood, and sleep. Significant linear discriminant functions were found for all subscales. Depressed mood predicted higher fatigue group membership for General, Mental, Emotional, and Physical Fatigue, and lower Vigor group membership. Poor sleep quality predicted higher General and Physical Fatigue, and lower Vigor. Less severe stage of cancer predicted higher Mental Fatigue and lower Vigor. Younger age predicted higher Mental and Emotional Fatigue, and lower Vigor. Hierarchical cluster analyses yielded four profiled subtypes of fatigue expression. The first cluster scored higher than the sample average on General, Physical, and Mental fatigue, at the average on Emotional fatigue, and below average on Vigor, while the second cluster was below average on all fatigue reports and above average on Vigor. The third was high in emotional and cognitive dimensions and low on physical or somatic aspects. The fourth showed the most severe fatigue across all five dimensions. In follow-up analyses, which did not include the third and fourth clusters due to disproportionate size, the first two clusters were significantly different on depressed mood but not on sleep quality, age, stage of cancer, or length of treatment. Findings suggest that age, stage, depressed mood, and sleep are all important predictors of fatigue, but there may be differential relationships between predictors and fatigue when subtypes of fatigue are considered. It is suggested that interventions targeting depressed mood and sleep may have the potential to reduce post-treatment fatigue given current limitations in treating fatigue directly.

Cancer-Related Fatigue

Author : Joachim Weis
Publisher : Springer
ISBN 13 : 1907673768
Total Pages : 80 pages
Book Rating : 4.9/5 (76 download)

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Book Synopsis Cancer-Related Fatigue by : Joachim Weis

Download or read book Cancer-Related Fatigue written by Joachim Weis and published by Springer. This book was released on 2014-11-12 with total page 80 pages. Available in PDF, EPUB and Kindle. Book excerpt: Cancer-related fatigue (CrF) is increasingly recognized as a significant problem for patients with cancer at all stages, including those undergoing therapy and in remission. In fact, studies have shown that CrF causes patients more distress than pain, nausea, or vomiting and yet fatigue is still often undertreated and rarely studied. However, several new treatments such as are being investigated to determine the most effective ways to manage this debilitating symptom and improve patient quality of life. Cancer-Related Fatigue will provide a concise overview of this condition, with an evidence-based discussion of diagnosis, treatment, and long-term management.

After the Cure

Author : Emily K. Abel
Publisher : NYU Press
ISBN 13 : 0814707351
Total Pages : 196 pages
Book Rating : 4.8/5 (147 download)

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Book Synopsis After the Cure by : Emily K. Abel

Download or read book After the Cure written by Emily K. Abel and published by NYU Press. This book was released on 2010-08-30 with total page 196 pages. Available in PDF, EPUB and Kindle. Book excerpt: From the book jacket: Chemo Brain. Fatigue. Chronic Pain. Insomnia. Depression. These are just a few of the ongoing, debilitating symptoms that plague some breast cancer survivors long after their treatments have officially ended. After The Cure is a compelling read filled with fascinating portraits of women who are living with the aftermath of breast cancer. Having heard repeatedly that the problems are all in your head, many don't know where to turn for help. The doctors who now refuse to validate their symptoms are often the very ones they depended on to provide life-saving treatments. Sometimes family members, who provided essential support through months of chemotherapy and radiation, don't believe them. Their work lives, already disrupted by both cancer and its treatment, are further undermined by the lingering symptoms. And every symptom is a constant reminder of the trauma of diagnosis, the ordeal of treatment, and the specter of recurrence. Most narratives about surviving breast cancer end with the conclusion of chemotherapy and radiation, painting stereotypical portraits of triumphantly healthy survivors, women who not only survive but emerge better and stronger than before. After The Cure allows us to hear the voices of those who are silenced by the optimistic breast cancer culture, women who live with a broad array of health problems long after therapy ends. Here, at last, survivors step out of the shadows and speak compellingly about their real stories, giving voice to the complicated, often bittersweet realities of life after the cure.

Adjuvant Therapy for Breast Cancer

Author : Monica Castiglione
Publisher : Springer Science & Business Media
ISBN 13 : 0387751157
Total Pages : 483 pages
Book Rating : 4.3/5 (877 download)

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Book Synopsis Adjuvant Therapy for Breast Cancer by : Monica Castiglione

Download or read book Adjuvant Therapy for Breast Cancer written by Monica Castiglione and published by Springer Science & Business Media. This book was released on 2009-07-11 with total page 483 pages. Available in PDF, EPUB and Kindle. Book excerpt: Adjuvant treatment is administered prior to or as follow up to surgical procedures for breast cancer. Proven success in using medical therapies allowing for breast conserving procedures or reducing risk of occurrence. Although there has been much progress towards a cure, including the introduction of new targeted therapies, metastasizing cancer remains highly incurable.

Improving Outcomes for Breast Cancer Survivors

Author : Patricia A. Ganz
Publisher :
ISBN 13 : 9783319163673
Total Pages : pages
Book Rating : 4.1/5 (636 download)

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Book Synopsis Improving Outcomes for Breast Cancer Survivors by : Patricia A. Ganz

Download or read book Improving Outcomes for Breast Cancer Survivors written by Patricia A. Ganz and published by . This book was released on 2015 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: In collaboration with the Breast Cancer Research Foundation (BCRF), this timely volume provides a comprehensive review on all areas of breast cancer survivorship research, highlighting research that is underway or in development. The range of topics covered include the biology and management of fatigue and cognitive dysfunction on breast cancer survivorship, the biology and management of Neuropathy and Arthralgias, the ongoing research on the biology of diet and lifestyle interventions in survivors, and more. With the tremendous growth in the number of breast cancer survivors, researchers have moved beyond describing the outcomes of breast cancer treatments and are focusing their research on understanding the mechanisms underlying the development of the late effects of breast cancer treatment, as well as the development and evaluation of interventions to mitigate some of the persistent symptoms--topics which are also explored in this volume. In addition, current research on how to improve survivorship and reduce recurrence of breast cancer through behavioral and lifestyle modifications is also discussed.

Putting Evidence Into Practice

Author : Linda H. Eaton
Publisher :
ISBN 13 : 9781935864042
Total Pages : 129 pages
Book Rating : 4.8/5 (64 download)

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Book Synopsis Putting Evidence Into Practice by : Linda H. Eaton

Download or read book Putting Evidence Into Practice written by Linda H. Eaton and published by . This book was released on 2011 with total page 129 pages. Available in PDF, EPUB and Kindle. Book excerpt: Supplement to "Putting Evidence into Practice: Improving Oncology Patient Outcomes" (Eaton and Tipton, 2009).

An Investigation Into the Biological Pathogenesis and Clinical Correlates of Cancer-related Fatigue in Disease-free Breast Cancer Patients

Download An Investigation Into the Biological Pathogenesis and Clinical Correlates of Cancer-related Fatigue in Disease-free Breast Cancer Patients PDF Online Free

Author : Ollie Minton
Publisher :
ISBN 13 :
Total Pages : pages
Book Rating : 4.:/5 (16 download)

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Book Synopsis An Investigation Into the Biological Pathogenesis and Clinical Correlates of Cancer-related Fatigue in Disease-free Breast Cancer Patients by : Ollie Minton

Download or read book An Investigation Into the Biological Pathogenesis and Clinical Correlates of Cancer-related Fatigue in Disease-free Breast Cancer Patients written by Ollie Minton and published by . This book was released on 2012 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: Background: 30-40% of women successfully treated for breast cancer experience chronic fatigue for up to five years after the end of therapy. They experience a number of associated problems including reduced quality of life, lower mood and concentration difficulties. The causes of these problems and the underlying biological pathogenesis of these symptoms are unclear. The primary objective of this research was to identify whether there were differences in objective activity, cognitive function and inflammatory cytokines between fatigued and non-fatigued women post-treatment. Methods: This was a cross-sectional observational study. Women were recruited from a nurse-led follow-up clinic at St George's hospital over a two-and-a-half-year period. These women were categorised on the basis of a semi-structured interview as to whether they met the criteria to be a case of cancer-related fatigue syndrome (CRFS) or acted as a control. All participants completed a set of questionnaires, activity recording, cognitive testing and had blood taken for analysis. Samples were sent to a commercial company for analyte panel testing (88 markers) and were also analysed using proteomic techniques (including mass spectrometry) to identify any differences in plasma proteins between groups. Results: 114 women were recruited; 45 cases and 69 controls. A between group analysis demonstrated statistically significant differences in sleep quality (p=0.02) and daytime activity (p=0.03) on activity recording, and slower processing speed (p=0.009) and impaired verbal memory (p=0.03) on cognitive testing. Blood analysis demonstrated statistically significant differences (p

Diagnosing and Treating Adult Cancers and Associated Impairments

Author : National Academies Of Sciences Engineeri
Publisher : National Academies Press
ISBN 13 : 9780309684002
Total Pages : pages
Book Rating : 4.6/5 (84 download)

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Book Synopsis Diagnosing and Treating Adult Cancers and Associated Impairments by : National Academies Of Sciences Engineeri

Download or read book Diagnosing and Treating Adult Cancers and Associated Impairments written by National Academies Of Sciences Engineeri and published by National Academies Press. This book was released on 2021-11-10 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: Cancer is the second leading cause of death among adults in the United States after heart disease. However, improvements in cancer treatment and earlier detection are leading to growing numbers of cancer survivors. As the number of cancer survivors grows, there is increased interest in how cancer and its treatments may affect a person's ability to work, whether the person has maintained employment throughout the treatment or is returning to work at a previous, current, or new place of employment. Cancer-related impairments and resulting functional limitations may or may not lead to disability as defined by the U.S. Social Security Administration (SSA), however, adults surviving cancer who are unable to work because of cancer-related impairments and functional limitations may apply for disability benefits from SSA. At the request of SSA, Diagnosing and Treating Adult Cancers and Associated Impairments provides background information on breast cancer, lung cancer, and selected other cancers to assist SSA in its review of the listing of impairments for disability assessments. This report addresses several specific topics, including determining the latest standards of care as well as new technologies for understanding disease processes, treatment modalities, and the effect of cancer on a person's health and functioning, in order to inform SSA's evaluation of disability claims for adults with cancer.

Late Effects of Childhood Cancer

Author : Daniel Green
Publisher : CRC Press
ISBN 13 : 0340808039
Total Pages : 437 pages
Book Rating : 4.3/5 (48 download)

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Book Synopsis Late Effects of Childhood Cancer by : Daniel Green

Download or read book Late Effects of Childhood Cancer written by Daniel Green and published by CRC Press. This book was released on 2003-12-26 with total page 437 pages. Available in PDF, EPUB and Kindle. Book excerpt: The treatment of childhood cancer has become increasingly successful over the last forty years, and during the last two decades in particular, and the overall cure rate is now 60-70%. This, in turn, has introduced new issues for the clinician as the number of long-term survivors has increased. Some of the therapies that have contributed most to the improvement in survival are now known to have serious consequences for the patient in later life, and many survivors will be affected by physical, educational and psychological disability to a lesser or greater degree. This definitive reference brings together all aspects of long-term effects of treatment for cancer during childhood in a single comprehensive volume. International in perspective, the book is structured according to complication rather than original site of malignancy for ease of reference. Topics covered include problems in the neurological system and special senses of sight and sound, cardiovascular, respiratory, gastrointestinal, urological and musculoskeletal complications, effects on the endocrine system and, in particular, future fertility, and secondary cancers. The book also reviews in detail the important issues of quality of life, prevention initiatives and strategies for long-term follow up. Key point summaries are included throughout, and the references are annotated to guide the reader quickly to seminal primary papers and key review articles. With an accessible and consistent approach throughout, Late Effects of Childhood Cancer is an invaluable source of information and guidance for pediatric oncologists, who need to keep fully informed in order to advise patients and their parents appropriately, and also for pediatric and adult endocrinologists, adult oncologists and other physicians to whom the patient with late effects may initially present.

Cancer Care for the Whole Patient

Author : Institute of Medicine
Publisher : National Academies Press
ISBN 13 : 0309134161
Total Pages : 455 pages
Book Rating : 4.3/5 (91 download)

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Book Synopsis Cancer Care for the Whole Patient by : Institute of Medicine

Download or read book Cancer Care for the Whole Patient written by Institute of Medicine and published by National Academies Press. This book was released on 2008-03-19 with total page 455 pages. Available in PDF, EPUB and Kindle. Book excerpt: Cancer care today often provides state-of-the-science biomedical treatment, but fails to address the psychological and social (psychosocial) problems associated with the illness. This failure can compromise the effectiveness of health care and thereby adversely affect the health of cancer patients. Psychological and social problems created or exacerbated by cancer-including depression and other emotional problems; lack of information or skills needed to manage the illness; lack of transportation or other resources; and disruptions in work, school, and family life-cause additional suffering, weaken adherence to prescribed treatments, and threaten patients' return to health. Today, it is not possible to deliver high-quality cancer care without using existing approaches, tools, and resources to address patients' psychosocial health needs. All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services. Cancer Care for the Whole Patient recommends actions that oncology providers, health policy makers, educators, health insurers, health planners, researchers and research sponsors, and consumer advocates should undertake to ensure that this standard is met.

Mindfulness-Based Cancer Recovery

Author : Linda Carlson
Publisher : New Harbinger Publications
ISBN 13 : 1608822354
Total Pages : 210 pages
Book Rating : 4.6/5 (88 download)

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Book Synopsis Mindfulness-Based Cancer Recovery by : Linda Carlson

Download or read book Mindfulness-Based Cancer Recovery written by Linda Carlson and published by New Harbinger Publications. This book was released on 2011-02-03 with total page 210 pages. Available in PDF, EPUB and Kindle. Book excerpt: A Mind-Body Approach to Healing If you have received a cancer diagnosis, you know that the hundreds of questions and concerns you have about what's to come can be as stressful as the cancer treatment itself. But research shows that if you mentally prepare yourself to handle cancer treatment by getting stress and anxiety under control, you can improve your quality of life and become an active participant in your own recovery. Created by leading psychologists specializing in oncology, the Mindfulness-Based Cancer Recovery program is based on mindfulness-based stress reduction (MBSR), a therapeutic combination of mindfulness meditation and gentle yoga now offered to cancer survivors and their loved ones in hundreds of medical centers, hospitals, and clinics worldwide. Let this book be your guide as you let go of fear and focus on getting well. With this eight-week program, you'll learn to: • Use proven MBSR skills during your treatment and recovery • Boost your immune function through meditation and healing yoga • Calm feelings of fear, uncertainty, and lack of control • Mindfully manage difficult symptoms and side effects • Discover your own capacity for healing and thriving after adversity

Physical Activity and Cancer

Author : Kerry S. Courneya
Publisher : Springer Science & Business Media
ISBN 13 : 3642042317
Total Pages : 389 pages
Book Rating : 4.6/5 (42 download)

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Book Synopsis Physical Activity and Cancer by : Kerry S. Courneya

Download or read book Physical Activity and Cancer written by Kerry S. Courneya and published by Springer Science & Business Media. This book was released on 2010-11-26 with total page 389 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book explores in depth the relation between physical activity and cancer control, including primary prevention, coping with treatments, recovery after treatments, long-term survivorship, secondary prevention, and survival. The first part of the book presents the most recent research on the impact of physical activity in preventing a range of cancers. In the second part, the association between physical activity and cancer survivorship is addressed. The effects of physical activity on supportive care endpoints (e.g., quality of life, fatigue, physical functioning) and disease endpoints (e.g., biomarkers, recurrence, survival) are carefully analyzed. In addition, the determinants of physical activity in cancer survivors are discussed, and behavior change strategies for increasing physical activity in cancer survivors are appraised. The final part of the book is devoted to special topics, including the relation of physical activity to pediatric cancer survivorship and to palliative cancer care.

The Link Between Inflammation and Cancer

Author : Angus G. Dalgleish
Publisher : Springer Science & Business Media
ISBN 13 : 0387262830
Total Pages : 260 pages
Book Rating : 4.3/5 (872 download)

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Book Synopsis The Link Between Inflammation and Cancer by : Angus G. Dalgleish

Download or read book The Link Between Inflammation and Cancer written by Angus G. Dalgleish and published by Springer Science & Business Media. This book was released on 2006-03-05 with total page 260 pages. Available in PDF, EPUB and Kindle. Book excerpt: A link between inflammation and cancer has been established many years ago, yet it is only recently that the potential significance of this connection has become apparent. Although several examples of chronic inflammatory conditions, often induced by persistent irritation and/or infection, developing into cancer have been known for some time, there has been a notable resistance to contemplate the possibility that this association may apply in a causative way to other cancers. Examples for such progression from chronic inflammation to cancer are colon carcinoma developing with increased frequency in patients with ulcerative colitis, and the increased incidence of bladder cancer in patients suffering from chronic Schistosoma infection. Inflammation and cancer have been recognized to be linked in another context for many years, i.e., with regards to pathologies resembling chronic lacerations or 'wounds that do not heal.' More recently, the immunology of wound healing has given us clues as to the mechanistic link between inflammation and cancer, in as much as wounds and chronic inflammation turn off local cell-mediated immune responses and switch on growth factor release as well the growth of new blood vessels - angiogenesis. Both of these are features of most types of tumours, which suggest that tumours may require an immunologically shielded milieu and a growth factor-rich environment.