Psoriasis Pictures, Symptoms, Causes and Treatments

 

What Is Psoriasis?

Psoriasis is a genetically programmed inflammatory disease that affects primarily the skin in about 3% of individuals in the United States. Psoriasis begins as a small scaling papule. When multiple papules coalesce, they form scaling plaques. These plaques tend to occur in the scalp, elbows, and knees.
 

Symptoms of Psoriasis

Although psoriatic plaques can be limited to only a few small areas, the condition can involve widespread areas of skin anywhere on the body. These plaques can be itchy, and when the scale is peeled away, small bleeding points may appear. Psoriasis tends to occur in areas of trauma. This condition often waxes and wanes spontaneously.
 

Nail Psoriasis

Many patients with psoriasis have abnormal nails. Psoriatic nails often have a horizontal white or yellow margin at the tip of the nail called distal onycholysis because the nail is lifted away from the skin. There can often be small pits in the nail plate, and the nail is often yellow and crumbly.
 

Psoriatic Arthritis

Psoriasis can be associated with a destructive arthritis called psoriatic arthritis. Damage can be serious enough to permanently damage the affected joints. Prevention of joint damage in such cases is very important.
 

What Causes Psoriasis?

It is now clear that there is a genetic basis for psoriasis. This hereditary predisposition is necessary before the disease can be triggered by environmental factors. White blood cells called T-cells mediate the development of the psoriatic plaques that we seen in the skin.
 

Psoriasis Triggers

The environmental factors that seem to trigger psoriasis include:

• streptococcal sore throat,
• trauma to the skin,
• certain drugs,
• alcohol in excess.

 

The Stigma of Psoriasis

There is plenty of evidence that extensive psoriasis can have a very significant negative effect on a patient’s self-image and emotions. This is especially true in social situations, although all aspects of life can be disturbed. Inverse psoriasis, which affects the genital skin, and scalp psoriasis can be particularly troubling. Psoriasis affecting the hands may make it impossible to interact normally with others.
 

Diagnosing Psoriasis

Psoriasis is often diagnosed by a competent physician or at least suspected on the basis of its appearance and distribution. Occasionally it may be necessary to remove a small piece of skin (a biopsy) and have it examined by a pathologist to confirm this conviction. If there are joint symptoms, X-rays and other laboratory tests may be in order. Psoriasis cannot be cured, but like many other medical conditions, it is controllable with treatment.
 

Psoriasis Treatment: Topicals

Since psoriasis mainly affects the skin, topical treatments are very useful because they are relatively safe, quite effective, and can be applied directly to the disease. They take the form of lotions, foams, creams, ointments, gels, and shampoos. They include topical steroids, tar preparations, and calcium- modulating drugs. The precise drug used and the form in which it is delivered depends on the areas involved. In widespread disease in patients with more than 10% of the body surface involved, it may not be practical to use topical medication. treatments.
 

Psoriasis Treatment: Phototherapy

For more extensive disease, a useful option is ultraviolet light exposure. Ultraviolet light (UVL) exposure can treat large areas of skin with few side effects if performed in the physician’s office. It should be kept in mind that all UVL causes mutational events, which can lead to skin cancer. At this time, the most popular type of UVL for psoriasis is called narrow-band UVB. Only a small portion of the UVL spectrum is used, which seems to be particularly beneficial for psoriasis and may of less carcinogenic potential. This UVB is quite different from the UVA, the wavelength available in tanning salons.

 

Psoriasis Treatment: Laser Therapy

There are lasers that produce UVL in wavelengths similar to narrow-band UVB. These can be quite effective for small plaques of psoriasis, but because the areas of skin that can be treated at one time are small, they are not practical for extensive disease.
 

Psoriasis Treatment: Oral Medications

There are a variety of drugs administered systemically that are useful in controlling psoriasis. The choice of which drug to use depends upon many factors which make this a very individual choice. Since these drugs are administered either orally or through the skin, they are more risky for the patient than topical medications. As a generalization, most seem to act by targeting portions of the immune system. The only exception currently is a drug called acitretin (Soriatane), which is structurally similar to vitamin A. Since the immune system is necessary in order to survive, systemic treatments do have a downside. Drugs like methotrexate and cyclosporine are administered orally and can affect the liver, kidney, and bone marrow.

Psoriasis Treatment: Biologics

A new class of drugs has recently been developed called biologics; they're called biologics because living cells synthesize them. Since these drugs are proteins, they cannot be administered orally and must be given by injection through the skin or by an intravenous infusion. These drugs are very precise in their target and block a single step in the immune process. This seems to have increased their safety profile when compared to older drugs. On the other hand, they are quite expensive.
 

atural Remedies for Psoriasis

Since the natural solar spectrum contains ultraviolet light, there is no question that heliotherapy (medicinal sunbathing) can be effective in controlling psoriasis. There is mounting evidence that increased body mass is associated with psoriasis and that heavier individuals are more difficult to treat. So a normal body mass is desirable. There is some dispute as to the role of diet in psoriasis, but a diet low in saturated fats is desirable for many reasons including weight control. So-called "natural or botanical" treatments have very little evidence to support their use.
 

Climatotherapy

At the edge of Israel's Dead Sea, there are a group of resorts that cater to psoriasis patients by offering a combination of graded solar exposure and the application of crude coal tar along with a spa-like experience. For those with the time and the money, this is a reasonable alternative to standard medical treatment.
 

Stress Reduction

Although there is no doubt that psoriasis is a potent inducer of stress, the evidence that stress causes psoriasis is sparse. Dealing with stress with or without psoriasis is a challenge for most people living in the 21st century.
 

Social Support

The National Psoriasis Foundation is an excellent source of accurate information as well as emotional support for afflicted patients.

Cervical Cancer:(Cancer of the Cervix)

Cervical Cancer (Cancer of the Cervix)

 

1. Cervical Cancer Slideshow Pictures
2. Cancer Symptoms Women Ignore Slideshow
3. Ovarian Cancer Slideshow Pictures

• Cervical cancer facts*
• What is the cervix?
• What is cancer?
• What are the risk factors and causes of cervical cancer?
• What are the symptoms of cervical cancer?
• How is cervical cancer diagnosed?
• How is staging of cervical cancer determined?
• What is the treatment for cervical cancer?
• What are methods of treatment for cervical cancer?
• How do I go about getting a second opinion?
• What follow-up care is involved after cervical cancer treatment?
• What support, research, and clinical trials information is available for cervical cancer patients?
• Patient Comments: Cervical Cancer - Risk Factors
• Patient Comments: Cervical Cancer - Symptoms
• Patient Comments: Cervical Cancer - Treatments
• Patient Comments: Cervical Cancer - Share Your Experience
• Find a local Oncologist in your town

Cervical cancer facts*

*Cervical cancer facts medical author: Melissa Conrad Stöppler, MD

• Causes and risk factors for cervical cancer have been identified and include human papillomavirus (HPV) infection, having many sexual partners, smoking, taking birth control pills, and engaging in early sexual contact.
• HPV infection may cause cervical dysplasia, or abnormal growth of cervical cells.
• Regular pelvic exams and Pap testing can detect precancerous changes in the cervix.
• Precancerous changes in the cervix may be treated with cryosurgery, cauterization, or laser surgery.
• The most common symptoms and signs of cervical cancer are abnormal vaginal bleeding, increased vaginal discharge, bleeding after going through menopause, pain during sex, and pelvic pain.
• Cervical cancer can be diagnosed using a Pap smear or other procedures that sample the cervix tissue.
• Chest X-rays, CT scan, MRI, and a PET scan may be used to determine the stage of cervical cancer.
• Cancer of the cervix requires different treatment than cancer that begins in other parts of the uterus.
• Treatment options for cervical cancer include radiation therapy, surgery, and chemotherapy.
• Two vaccines, Gardasil and Cervarix, are available to prevent HPV infection.
• The prognosis of cervical cancer depends upon the stage and type of cervical cancer and the tumor size.

 

What is the cervix?

The cervix is part of a woman's reproductive system. It's in the pelvis. The cervix is the lower, narrow part of the uterus (womb).
The cervix is a passageway:

• The cervix connects the uterus to the vagina. During a menstrual period, blood flows from the uterus through the cervix into the vagina. The vagina leads to the outside of the body.
• The cervix makes mucus. During sex, mucus helps sperm move from the vagina through the cervix into the uterus.
• During pregnancy, the cervix is tightly closed to help keep the baby inside the uterus. During childbirth, the cervix opens to allow the baby to pass through the vagina.

What is cancer?

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the cervix and other organs of the body.
Normal cervical cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.
Sometimes, this process goes wrong. New cells form when the body does not need them, and old or damaged cells do not die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.
Growths on the cervix can be benign (not cancer) or malignant (cancer):

• Benign growths (polyps, cysts, or genital warts):
  • are rarely a threat to life
  • don't invade the tissues around them
• Malignant growths (cervical cancer):
  • may become a threat to life if not found soon enough
  • can invade nearby tissues and organs
  • can spread to other parts of the body

Cervical cancer begins in cells on the surface of the cervix. Over time, the cervical cancer can invade more deeply into the cervix and nearby tissues.
Cervical cancer cells can spread by breaking away from the cervical tumor. They can travel through lymph vessels to nearby lymph nodes. Also, cancer cells can spread through the blood vessels to the lungs, liver, or bones. The process of spreading of cancer cells from the tissue in which they arise to other tissues elsewhere is called metastasis.
After spreading, cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. See the Staging section for information about cervical cancer that has spread.

Risk factors

When you get a diagnosis of cervical cancer, it's natural to wonder what may have caused the disease. Doctors usually can't explain why one woman develops cervical cancer and another doesn't.
However, we do know that a woman with certain risk factors may be more likely than other women to develop cervical cancer. A risk factor is something that may increase the chance of developing a disease.
Studies have found that infection with the virus called HPV is the cause of almost all cervical cancers. More than half of women by the age of 50 have been exposed to HPV, but most HPV infections clear up on their own. An HPV infection with a high risk type of HPV that doesn't go away can cause cervical cancer in some women.
Other risk factors, such as smoking, can act to increase the risk of cervical cancer among women infected with HPV even more.
A woman's risk of cervical cancer can be reduced by getting regular cervical cancer screening tests. If abnormal cervical cell changes are found early, cancer can be prevented by removing or killing the changed cells before they become cancer cells.
Another way a woman can reduce her risk of cervical cancer is by getting an HPV vaccine before becoming sexually active (between the ages of 9 and 26). Even women who get an HPV vaccine need regular cervical cancer screening tests. Vaccines reduce a person's  risk of getting an infection, but do not prevent such infections in every vaccinated person.

Symptoms

Early cervical cancers usually don't cause symptoms. When the cancer grows larger, women may notice abnormal vaginal bleeding:

• Bleeding that occurs between regular menstrual periods
• Bleeding after sexual intercourse, douching, or a pelvic exam
• Menstrual periods that last longer and are heavier than before
• Bleeding after going through menopause

Women may also notice...

• Increased vaginal discharge
• Pelvic pain
• Pain during sex

Cervical cancer, infections, or other health problems may cause these symptoms. A woman with any of these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

 

Diagnosis

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If you have symptoms of cervical cancer, your doctor will try to find out what's causing the problems. You may have the following tests:

• Lab tests: The doctor or nurse scrapes a sample of cells from the cervix. For a Pap test, the lab checks the sample for cervical cancer cells or abnormal cells that could become cancer later if not treated. For an HPV test, the same or a similar sample is tested for HPV infection. HPV can cause cell changes and cervical cancer.
• Cervical exam: The doctor uses a colposcope to look at the cervix. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. This exam is usually done in the doctor's office or clinic.
• Tissue sample: The removal of tissue to look for cancer cells is a biopsy. Most women have cervical tissue removed in the doctor's office, and usually only local anesthesia is needed.

The doctor will remove tissue in one of the following ways:

• Punch biopsy: The doctor uses a sharp tool to pinch off small samples of cervical tissue.
• LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of cervical tissue.
• Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from the cervical canal. Some doctors may use a thin, soft brush instead of a curette.
• Cone biopsy: The doctor removes a cone-shaped sample of tissue. A cone biopsy lets the pathologist look at the tissue beneath the surface of the cervix to learn whether it has abnormal cells. The doctor may do this test in the hospital under general anesthesia.

A pathologist checks the tissue under a microscope for cancer cells. In most cases, a biopsy is the only sure way to tell whether cancer is present.
Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Some women also feel some pain similar to menstrual cramps. Your doctor can suggest medicine that will help relieve any pain.
 You may want to ask the doctor these questions before having a biopsy:

• Which biopsy method do you recommend?
• How will tissue be removed?
• Will I have to go to the hospital?
• How long will it take? Will I be awake? Will it hurt?
• Are there any risks? What are the chances of infection or bleeding after the test?
• For how many days afterward should I avoid using tampons, douching, or having sex?
• Can the test affect my ability to get pregnant and have children?
• How soon will I know the results? Who will explain them to me?
• If I do have cancer, who will talk to me about the next steps? When?

Staging

If the biopsy shows that you have cancer, your doctor will need to learn the extent (stage) of the disease to help you choose the best treatment. The stage is based on whether the cancer has invaded nearby tissues or spread to other parts of the body. Cervical cancer spreads most often to nearby tissues in the pelvis or to lymph nodes. It may also spread to the lungs, liver, or bones.
When cancer spreads from its original place to another part of the body, the new tumor has the same kind of cancer cells and the same name as the original tumor. For example, if cervical cancer spreads to the lungs, the cancer cells in the lungs are actually cervical cancer cells. The disease is metastatic cervical cancer, not lung cancer. It's treated as cervical cancer, not as lung cancer. Doctors sometimes call the new tumor in the lung "distant" disease or a distant metastasis.
Your doctor will do a pelvic exam, will feel for swollen lymph nodes, and may remove additional tissue. To learn the extent of disease, your doctor may order one or more tests:

• Chest X-ray: An X-ray of the chest can often show whether cancer has spread to the lungs.
• CT scan (CAT scan): An X-ray machine linked to a computer takes a series of detailed pictures of your pelvis, abdomen, or chest. Before a CT scan, you may receive contrast material by injection in your arm or hand, by mouth, or by enema. The contrast material makes abnormal areas easier to see. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan.
• MRI: A powerful magnet linked to a computer makes detailed pictures of your pelvis and abdomen. Before MRI, you may receive an injection of contrast material. MRI can show whether cancer has invaded tissues near the cervix or has spread from the cervix to tissues in the pelvis or abdomen.
• PET scan: Cancer cells often take up or concentrate sugar- or glucose- more than normal tissues. Radioactive glucose can be given as an injection into a vein. Pictures are then made using a machine which images the areas of radioactive glucose in the body. Combining those images with a CT scan can provide excellent information on the presence or absence of spread of the cancer.

The stage is based on where cancer is found. These are the stages of invasive cervical cancer:

• Stage I: Cancer cells are found only in the cervix.
• Stage II: The tumor has grown through the cervix and invaded the upper part of the vagina. It may have invaded other nearby tissues but not the pelvic wall (the lining of the part of the body between the hips) or the lower part of the vagina.
• Stage III: The tumor has invaded the pelvic wall or the lower part of the vagina. If the tumor is large enough to block one or both of the tubes through which urine passes from the kidneys, lab tests may show that the kidneys aren't working well.
• Stage IV: The tumor has invaded the bladder or rectum. Or, the cancer has spread to other parts of the body, such as the lungs.

Treatment

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Treatment options for women with cervical cancer are...

• Surgery
• Radiation therapy
• Chemotherapy
• A combination of these methods

The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. The treatment choice may also depend on whether you would like to become pregnant someday.
Your doctor may refer you to a specialist, or you may ask for a referral. You may want to see a gynecologic oncologist, a doctor who specializes in treating female cancers. Other specialists who treat cervical cancer include gynecologists, medical oncologists, and radiation oncologists.
Your health care team may also include an oncology nurse and a registered dietitian. Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer treatments often damage healthy cells and tissues, side effects are common. These side effects depend on many factors, including the type of treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.
At any stage of the disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. You can get information about coping on NCI's website at http://www.cancer.gov/cancertopics/coping.
Also, you can get information about supportive care from NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). Or, chat using LiveHelp, NCI's instant messaging service, at http://www.cancer.gov/livehelp.
You may want to talk with your doctor about taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for women with all stages of cervical cancer. See the section on Taking Part in Cancer Research 4.
You may want to ask the doctor these questions before treatment begins:

• What is the stage of my disease? Has the cancer spread? If so, where?
• May I have a copy of the report from the pathologist?
• What are my treatment choices? Which do you recommend for me? Will I have more than one kind of treatment?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment? What can we do to control the side effects?
• What can I do to prepare for treatment?
• Will I have to stay in the hospital? If so, for how long?
• What is the treatment likely to cost? Will my insurance cover the cost?
• How will treatment affect my normal activities?
• How may treatment affect my sex life?
• Will I be able to get pregnant and have children after treatment? Should I preserve eggs before treatment starts?
• What can I do to take care of myself during treatment?
• What is my chance of a full recovery?
• How often will I need checkups after treatment?
• Would a research study (clinical trial) be right for me?

Surgery

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Surgery is an option for women with Stage I or II cervical cancer. You and your surgeon can talk about the types of surgery and which may be right for you.
If you have a small tumor, the type of surgery may depend on whether you want to get pregnant and have children later on. Some women with very early cervical cancer may decide with their surgeon to have only the cervix, part of the vagina, and the lymph nodes in the pelvis removed (radical trachelectomy).
Other women may choose to have the cervix and uterus removed (complete hysterectomy). The surgeon may also remove some tissue around the cervix, part of the vagina, the fallopian tubes, or the ovaries. In addition, the surgeon may remove lymph nodes near the tumor.
It's common to feel tired or weak for a while after surgery for cervical cancer. The time it takes to heal is different for each woman. You'll probably be able to leave the hospital within a couple of days. Most women return to their normal activities within 4 to 8 weeks after surgery.
You may have pain or discomfort for the first few days after surgery. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your health care team. After surgery, they can adjust the plan if you need more pain control.
After a trachelectomy, some women need to have a tube put into the bladder to drain urine. It usually can be removed a few days after surgery.
After a hysterectomy, some women become constipated or have nausea and vomiting. In addition, some women lose control of their bladder or have trouble emptying their bladder. These effects are usually temporary. After a hysterectomy, you'll stop having menstrual periods, and you won't be able to become pregnant.
After the ovaries are removed, menopause occurs at once. You may have hot flashes, vaginal dryness, and night sweats. These symptoms are caused by the sudden loss of female hormones. Talk with your health care team about your symptoms so that you can develop a treatment plan together. There are drugs and lifestyle changes that can help, and most symptoms go away or lessen with time.
Surgery to remove lymph nodes may cause swelling (lymphedema) in one or both legs. Ask your health care team about how you may prevent or control the swelling. Information about lymphedema is available on NCI's website at http://www.cancer.gov/cancertopics/coping.
For some women, surgery to remove the cervix and nearby tissues can affect sexual intimacy. You may have feelings of loss that make intimacy difficult. Sharing these feelings with your partner may be helpful. Sometimes couples talk with a counselor to help them express their concerns.
You may want to ask the doctor these questions before having surgery:

• Do you recommend surgery for me? If so, which kind? Will my ovaries be removed? Do I need to have lymph nodes removed?
• What is the goal of surgery?
• What are the risks of surgery?
• How will I feel after surgery? If I have pain, how will it be controlled?
• How long will I have to be in the hospital?
• Will I have any lasting side effects?
• When will I be able to resume normal activities?

Radiation therapy

Radiation therapy uses high-energy rays to kill cancer cells. It's an option for women with any stage of cervical cancer. Women with early cervical cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. Women with cancer that extends beyond the cervix may have radiation therapy and chemotherapy.
Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types:

• External radiation therapy: A large machine directs radiation at your pelvis or other areas with cancer. The treatment usually is given in a hospital or clinic. You may receive external radiation therapy 5 days a week for several weeks. Each treatment takes only a few minutes.
• Internal radiation therapy (also called brachytherapy): A narrow cylinder is placed inside your vagina, and a radioactive substance is loaded into the cylinder. Usually, a session of internal radiation therapy lasts only a few minutes. The cylinder and substance are removed, and you can go home. The short session may be repeated two or more times over several weeks. When the radioactive substance is removed, no radioactivity is left in your body. With a less common method of internal radiation therapy, you may stay in the hospital for several days during treatment.

Although radiation therapy is painless, it may cause side effects. The side effects depend mainly on how much radiation is given and which part of your body is treated. Radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. You may lose hair in your genital area. Also, skin on the abdomen and pelvis may become red, dry, and tender.
You may have dryness, itching, or burning in your vagina. Your doctor may advise you to wait until a few weeks after radiation treatment ends to have sex.
You are likely to become tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Although the side effects of radiation therapy can be upsetting, they can usually be treated or controlled. Talk with your doctor or nurse about ways to relieve discomfort.
It may also help to know that most side effects go away when treatment ends. However, you may want to discuss with your doctor the possible long-term effects of radiation therapy. For example, radiation therapy may make the vagina narrower. A narrow vagina can make sex or follow-up exams difficult. There are ways to prevent this problem. If it does occur, however, your health care team can tell you about ways to expand the vagina.
Another possible long-term effect is damage to the ovaries. Menstrual periods usually stop, and women may have hot flashes and vaginal dryness. Menstrual periods may return for some women, especially younger women. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts.
You may want to ask the doctor these questions before having radiation therapy:

• What is the goal of this treatment?
• How will the radiation be given?
• Will I need to stay in the hospital? If so, for how long?
• When will the treatments begin?
• How often will I have them? When will they end?
• How will I feel during treatment? Are there side effects?
• How will we know if the radiation therapy is working?
• Will I be able to continue my normal activities during treatment?
• How will radiation therapy affect my sex life?
• Are there lasting side effects?

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. For the treatment of cervical cancer, chemotherapy is usually combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy may be used alone.
Most drugs for cervical cancer are given directly into a vein (intravenously) through a thin needle. Some drugs can be taken by mouth. Most women receive chemotherapy in a clinic or at the doctor's office. Drugs that are swallowed may be taken at home instead. Some women need to stay in the hospital during treatment.
The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

• Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If the levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. They may also give you medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture for a while. Ultimately it will return to being naturally as it was before.
• Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.

Other side effects include skin rash, tingling or numbness in your hands and feet, hearing problems, loss of balance, joint pain, or swollen legs and feet. Your health care team can suggest ways to control many of these problems. Most go away when treatment ends.
You may want to ask the doctor these questions before having chemotherapy:

• Why do I need this treatment?
• Which drug or drugs will I have?
• How do the drugs work?
• What are the expected benefits of the treatment?
• What are the risks and possible side effects of treatment? What can we do about them?
• When will treatment start? When will it end?
• How will treatment affect my normal activities? 

Second opinion

Before starting treatment, you might want a second opinion about your diagnosis, stage of cancer, and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion.
If you get a second opinion, the second doctor may agree with your first doctor's diagnosis and treatment plan. Or, the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at all of your options.
It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.
There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, or a nearby hospital or medical school for names of specialists.

Nutrition

Eating well is important before, during, and after cancer treatment. You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.
Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, poor appetite, nausea, vomiting, mouth blisters, and other side effects of treatment can make it hard for you to eat.
Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.

Follow-up care

You'll need regular checkups (such as every 3 to 6 months) after treatment for cervical cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, contact your doctor.
Cervical cancer may come back after treatment. Your doctor will check for the return of cancer. Checkups may include a physical exam, Pap test, and chest X-ray.
You may want to ask your doctor these questions after you have finished treatment:

• How often will I need checkups?
• How often will I need a Pap test?
• What other follow-up tests do you suggest for me?
• Between checkups, what health problems or symptoms should I tell you about?

Sources of support

Learning that you have cervical cancer can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to need help coping with the feelings that a diagnosis of cancer can bring.
Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities.
Here's where you can go for support:

• Doctors, nurses, and other members of your health care team can answer questions about treatment, working, or other activities.
• Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.
• Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with cancer and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.
• NCI's Cancer Information Service can help you locate programs, services, and NCI publications. Call 1-800-4-CANCER (1-800-422-6237). Or, chat using LiveHelp, NCI's instant messaging service, at http://www.cancer.gov/livehelp.
• Your doctor or a sex counselor may be helpful if you and your partner are concerned about the effects of cervical cancer on your sex life. Ask your doctor about possible treatment of side effects and whether these effects are likely to last. Whatever the outlook, you and your partner may find it helps to discuss your concerns.

Taking part in cancer research

Doctors all over the world are conducting many types of clinical trials (research studies in which people volunteer to take part). Research has already led to advances in the prevention, diagnosis, and treatment of cervical cancer.
Doctors continue to search for new and better ways to treat cervical cancer. They are testing new treatments, including new drugs, combinations, and schedules. Some studies are combining surgery, chemotherapy, and radiation therapy.
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Association between falls in elderly women and chronic diseases and drug use

Association between falls in elderly women and chronic diseases and drug use: cross sectional study

Debbie A Lawlor, senior lecturer in epidemiology,¹ Rita Patel, project coordinator,¹ and Shah Ebrahim, professor of epidemiology of ageing¹

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Abstract

Objective To assess the associations between having had a fall and chronic diseases and drug use in elderly women.

Design Cross sectional survey, using data from the British women's heart and health study.

Setting General practices in 23 towns in Great Britain.

Participants 4050 women aged 60-79 years.

Main outcome measure Whether women had had falls in the previous 12 months.

Results The prevalence of falling increased with increasing numbers of simultaneously occurring chronic diseases. However, no such relation with falling was found in the fully adjusted data for the number of drugs used. Circulatory disease, chronic obstructive pulmonary disease, depression, and arthritis were all associated with an increased odds of falling. The fully adjusted, population attributable risk of falling associated with having at least one chronic disease was 32.2% (95% confidence interval 19.6% to 42.8%). Only two classes of drugs (hypnotics and anxiolytics, and antidepressants) were independently associated with an increased odds of falling. Each class was associated with an increase of about 50% in the odds of falling, and each had a population attributable risk of < 5%.

Conclusion Chronic diseases and multiple pathology are more important predictors of falling than polypharmacy.

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Introduction

Falls among elderly people are common and are associated with increased morbidity, disability, social isolation, and a lower quality of life and with early entry into residential care in this group.¹ A number of chronic diseases are associated with a higher risk of falling, as are several classes of drugs, particularly tranquillisers and antidepressants.^1-3 However, few studies have assessed the independent associations of a range of risk factors in a single study group. We aimed to assess the independent associations of chronic diseases and drug use and the risk of falls in a group of women aged 60-79 years and living in the community.

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Methods

Participants

The women were participants in the British women's heart and health study. Full details of the selection of participants and measurements taken have been reported in previous studies.^4-6 We used the British regional heart study framework to randomly select women aged 60-79 from general practice lists in 23 towns in England, Scotland, and Wales. No women were excluded from the study, and all 7166 women in the age range, regardless of whether they normally lived in private accommodation, a residential home, or a nursing home, and irrespective of medical conditions, were invited to participate. Transport to examination centres was offered to immobile and frail women. Invitations were sent to the women, and two reminders were sent to non-responders. A total of 4286 women (60% of those invited) participated. Baseline data (from a self completed questionnaire, interviews by a research nurse, physical examination, and review of primary care medical records) were collected between April 1999 and March 2001.

Assessment of falls

In the self completed questionnaire participants were asked whether they had had a fall in the previous 12 months, how many times they had fallen, and whether they had received medical attention for any falls. No specific definition of a fall was given in these questions. As in other studies, we defined frequent falling as at least two falls in the previous 12 months.⁷

Assessment of chronic diseases

We collated details of clinical diagnoses of each of the women's chronic diseases, together with the dates of first diagnosis, from a combination of review of primary care medical records, interviews by a research nurse, and the participants' responses to the questionnaire.^4-6 Coronary heart disease was defined as any previous diagnosis of myocardial infarction or angina. Circulatory disease was defined as any diagnosis of myocardial infarction, angina, stroke, transient ischaemic attack, aortic artery disease, or peripheral artery disease. Chronic obstructive pulmonary disease included asthma and chronic bronchitis, and eye disease included cataracts and glaucoma.

Assessment of current drug use

Participants were asked to bring all their current medicines to the clinic visit, and at the research nurse's interview a full drug history was taken. Drugs were coded according to the British National Formulary: hypnotics and anxiolytics (drugs in section 4.1); antidepressants (4.3); any central nervous system drugs (4.1 to 4.11); analgesics (4.7 and 10.1.1); cardiovascular system drugs (2.1 to 2.12); endocrine system drugs (6.1 to 6.7); and respiratory system drugs (3.1 to 3.3).⁸ In analysing the data on analgesic drugs we did a sensitivity analysis in which non-steroidal anti-inflammatory drugs were not included in the definition (only drugs in section 4.7 were included). The results of this sensitivity analysis did not differ significantly from the results presented here.

Other measurements

We measured blood pressure with a Dinamap 1846SX vital signs monitor (GE Clinical Services, Northampton). We took two measurements in succession, with a 1 minute interval, on the right arm, with the participant seated and the arm supported on a cushion at chest level. Participants were then asked to stand, with their arms relaxed and at their sides, and two standing measurements were taken. The mean of the two measurements was used in all analyses. Postural hypotension was defined as a reduction between sitting and standing of ≥ 20 mm Hg in systolic blood pressure or ≥ 10 mm Hg in diastolic pressure.⁹ We also assessed the association of low standing blood pressure (systolic ≤ 100 mm Hg or diastolic ≤ 60 mm Hg) with falls.

We derived two measures of alcohol consumption from the questionnaire data: regular daily consumption (or consumption on most days) of any alcohol; and heavy drinking, defined as ≥ 14 units of alcohol a week. Social class was derived, in the case of married women, from the longest held occupation of the husband or, in single women, from her own longest held occupation. Social class was defined according to the registrar general's classification.

Statistical analysis

We used multiple logistic regression to assess associations with falls. Of the 4286 women who participated 425 could not be assigned an adult social class. These women were likely to have been married to unemployed men, and as their risk factor profiles were similar to those of women in social class V they were allocated to this group, as in previous analyses.⁵ Sensitivity analyses in which these women were excluded showed no significant difference in the findings. There were a few missing data for each of the other variables, and the multivariable analyses were conducted on the 3742 women (92%) with complete data on all the variables that were included in the final fully adjusted model. These 3742 women did not differ from the women without complete data in age or in the prevalence of any falls, frequent falls, or falls where the women received medical attention (P > 0.4 for all variables). We estimated population attributable risks of falling for risk factors from the fully adjusted logistic regression models, using maximum likelihood estimates as proposed by Greenland and Drescher.¹⁰ In all analyses we used robust standard errors, which take into account the clustering effects in each town, to calculate 95% confidence intervals. We used Stata version 8.0 (StataCorp, College Station, TX, 2002) for all statistical analyses.

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Results

Of the 4286 participants 4050 (94%) provided data on falls. There were no differences between the women who provided these data and the other women in age, prevalence of any chronic diseases, drug use, or socioeconomic position (P > 0.15 for all variables). Of the 4050 women 686 had fallen at least once in the previous 12 months, giving a prevalence of 16.9% (95% confidence interval 15.8% to 18.1%). The prevalence of frequent falling was 7.0% (6.2% to 7.8%) and of falls where medical attention was given was 6.8% (6.0% to 7.6%).

Women who had fallen at least once in the previous 12 months were older than women who had not fallen and were more likely to have chronic diseases, more likely to be taking drugs, and had a higher body mass index (table 1). Postural hypotension and low standing blood pressure were not associated with falling. The women who had fallen had a lower mean haemoglobin concentration, and this inverse association remained even when data were adjusted for social class, body mass index, chronic diseases, and each class of drug used. The fully adjusted odds ratio of any falls for an increase in haemoglobin concentration of one standard deviation was 0.90 (0.81 to 0.99). Very few of the women had anaemia: no women had a haemoglobin concentration below 80 g/l, 15 had a concentration below 100 g/l, and 222 (5.5%) had a concentration below 120 g/l. Alcohol consumption was not related to falling. In the 12 months before the women's baseline examination 55 women (1.28%) had had a fractured hip (15 women) or wrist (44 women). Women who had had a fall in the previous 12 months were much more likely to have had a fracture than the women who hadn't had a fall (table 1).

Table 1

Characteristics of women who had had no fall or at least one fall in the previous 12 months. Values are percentage of women (95% confidence interval), adjusted for age, except where otherwise indicated

Drug use and falls

Just over 70% (2887) of the women were taking at least one drug, and 622 (15.4%) were taking five or more drugs. There was a strong linear association between the number of drugs that women took and whether they had had a fall (figure). However, the association was not significant when the data were adjusted for chronic diseases and other potential confounding factors. The crude odds ratio for a fall in the previous 12 months for each additional drug taken was 1.14 (1.10 to 1.19), but the fully adjusted odds ratio was 1.01 (0.96 to 1.06). Linear associations between frequent falls and falls receiving medical attention and the number of drugs taken were similar, with the fully adjusted models showing no significant associations. Use of hypnotics or anxiolytics and use of antidepressants were associated with an increased odds of falling, even with adjustment for chronic disease status (including ever having had a diagnosis of depression) and other potential confounding factors (table 2). In the fully adjusted analyses analgesics, cardiovascular system drugs, endocrine system drugs, and respiratory disease drugs were not independently associated with having had a fall (table 2).

Figure 1

Prevalence of falls in the previous 12 months and number of drugs taken (crude data and fully adjusted for age, each chronic disease, body mass index, alcohol consumption, haemoglobin concentration, and social class)

Table 2

Relation between drug use and falls in previous 12 months in 3742 UK women aged 60-79 years. Values are crude or fully adjusted^* odds ratios (95% confidence interval)

Chronic disease and falls

Nearly three quarters (2961) of the women had at least one chronic disease. There was a marked linear trend of increasing odds of falling with increasing number of chronic diseases (figure). This association remained even after adjustment for drug use and other potential confounding factors. The crude odds ratio for any fall in the previous 12 months for each additional simultaneously occurring disease was 1.46 (1.36 to 1.56), and the fully adjusted odds ratio was 1.37 (1.25 to 1.49). We found similar linear trends for the association between increasing numbers of simultaneously occurring chronic diseases and frequent falls and treated falls, and these associations remained significant in the fully adjusted models.

Figure 2

Prevalence of falls in the previous 12 months and number of simultaneous chronic diseases (crude data and fully adjusted for age, each drug taken, body mass index, alcohol consumption, haemoglobin concentration, and social class)

Circulatory disease, chronic obstructive pulmonary disease, depression, and arthritis were each associated with a higher odds of falling, even with adjustment for drug use and other potential confounding factors (table 3). The population attributable risk of having had at least one fall in the previous 12 months, estimated from the fully adjusted models, was 6.2% (2.0% to 10.0%) for coronary heart disease, 6.2% (1.6% to 10.5%) for circulatory disease, 8.0% (3.3% to 12.4%) for chronic obstructive pulmonary disease, 9.4% (5.4% to 13.3%) for depression, and 17.4% (10.4% to 23.9%) for arthritis. The fully adjusted odds ratio of having had a fall in the previous 12 months associated with having at least one of the chronic diseases in table 3 was 1.81 (1.42 to 2.31), and the population attributable risk was 32.2% (19.6% to 42.8%). When we stratified the analyses by the year in which the participant's disease was first diagnosed, we found positive associations between falls and diseases diagnosed before (including up to 10 years before) the year in which the women had a fall.

Table 3

Relation between diagnoses of chronic diseases and falls in previous 12 months in 3742 UK women aged 60-79 years. Values are crude or fully adjusted^* odds ratios (95% confidence interval)

Effects of combined multiple pathology and polypharmacy

When number of drugs taken and number of chronic diseases were included in the same regression model they combined multiplicatively. The odds ratio for a fall for each additional chronic disease, adjusted for number of drugs taken, was 1.39 (1.29 to 1.51), and that for each additional drug taken, adjusted for number of chronic diseases, was 1.05 (1.01 to 1.09). There was no strong evidence of a statistical interaction between number of drugs and number of chronic diseases (P = 0.16) and no evidence of statistical interactions between any of the individual chronic diseases and their relevant treatment (P > 0.15 for all diseases).

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Discussion

The risk of falling rose with the number of drugs taken and the number of chronic diseases each woman had, but the association was stronger for multiple pathology than for polypharmacy and remained in the fully adjusted analyses. The population attributable risk of falling associated with having any chronic disease was much higher (32%) than that associated with use of psychotropic drugs (between 2% and 5%). Thus in public health terms targeting prevention and control of chronic diseases rather than polypharmacy may be a more useful strategy for preventing falls in elderly people. Factors commonly supposed to be associated with falls, such as postural hypotension, alcohol consumption, and reduced physiological reserve (as shown by low forced expiratory volume in 1 second) were not associated with falls in this study.^11,12 Contrary to evidence in previous reviews that risk factors differ for single falls, frequent falling, and treated falls, we found similar risk factor profiles for the different types of fall.^13,14

Limitations of the study

Our response rate (60%) is moderate but consistent with other large contemporary epidemiological surveys.¹⁵ As reported previously our respondents were slightly younger than non-respondents and were less likely to have a primary care medical record of stroke or diabetes, although the prevalence of coronary heart disease and cancer did not vary between respondents and non-respondents.⁴ Because chronic diseases are associated with falling we may have underestimated the prevalence of falls. The associations of chronic diseases and drug use with falling would only be exaggerated if the associations among non-respondents were in the opposite direction to the associations among responders or if they were non-existent, both of which are unlikely.

Our study is cross sectional and may therefore be susceptible to reverse causality. With respect to the effects of antidepressants and hypnotics or anxiolytics, it is possible that having had a fall may lead to anxiety or depression and therefore treatment for these conditions. However, assessing the association between drug use and the prevalence of falling is relevant, because the plausible mechanism by which central nervous system drugs result in falls is related to their contemporary use.¹⁶ That there was an association between falls and number of chronic diseases among women whose diagnosis had been made before the year of the fall indicates that these associations are not due to reverse causality.

We could not assess the effect of all the major chronic diseases that affect this age group. In particular we did not collect information on cognitive function. However, that the participants were able to complete a detailed health questionnaire suggested that few if any women had severe dementia. Elderly people may under-report falls.¹⁷ Any such misclassification is likely to be non-systematic and would therefore dilute the associations. We used a crude indicator of the severity of falls: whether the participant had had medical attention. Although having received medical attention may indicate a greater severity of fall, it also reflects sociodemographic and personal factors that influence the likelihood of getting medical care after a fall.

What is already known on this topic

A number of chronic diseases, use of tranquillisers and antidepressants, and polypharmacy are associated with an increased risk of falling, although the independent associations of particular diseases and types of drug are unclear

What this study adds

The risk of falling rises with the number of simultaneous chronic diseases

Elderly women with circulatory diseases, chronic obstructive pulmonary disease, arthritis, and depression are at a higher risk of falling, and chronic diseases may account for 30% of falls in this group

Anxiolytics, hypnotics, and antidepressants are the only classes of drugs that are independently associated with falling

Implications

As in other studies, our results show an association between the number of psychotropic drugs taken and the risk of falling.^3,7 Although the population attributable risk of falling associated with these drugs was small, they may be an important cause of morbidity in people using them. Trials have shown that gradual withdrawal of psychotropic drugs is feasible among elderly people and is associated with a decreased risk of falling.¹⁸

Chronic diseases may increase the risk of falls through direct effects of the disease and indirect effects, such as reduced physical activity, muscle weakness, and poor balance. Perhaps because observational research has focused more on drug use than chronic diseases, the effect of specific chronic diseases on the risk of falling has not been the main focus of controlled trials of interventions to prevent falls, although the inclusion of exercises specifically aimed at reducing falls as well as at improving cardiovascular fitness in cardiac rehabilitation programmes has been recommended.¹⁹ Chronic diseases and multiple pathology, rather than polypharmacy, may be the most important predictors of falling.

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Notes

Acknowledgments: The British women's heart and health study is co-directed by SE, Peter Whincup, Goya Wannamethee, and DAL. We thank Carol Bedford, Alison Emerton, Nicola Frecknall, Karen Jones, Mark Taylor, and Katherine Wornell for collecting and entering data, all the general practitioners and their staff who supported data collection, and the women who participated in the study.

Contributors: All authors developed the study's aim and design and managed its data. DAL undertook the initial analysis and coordinated the writing of the paper. All authors contributed to the final version. DAL will act as guarantor for the paper.

Funding: The British women's heart and health study is funded by the Department of Health. DAL is funded by a Medical Research Council and Department of Health training fellowship.

Competing interests: None declared.

Ethical approval: Local ethics committees approved the study, and 99.4% of participants gave written informed consent for their medical records to be available.

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References

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3. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis. I. Psychotropic drugs. J Am Geriatr Soc 1999;47: 30-9. [PubMed]

4. Lawlor DA, Bedford C, Taylor M, Ebrahim S. Geographic variation in cardiovascular disease, risk factors and their control in older women: British women's heart and health study. J Epidemiol Community Health 2003;57: 134-40. [PMC free article] [PubMed]

5. Lawlor DA, Ebrahim S, Davey Smith G. Socioeconomic position in childhood and adulthood and insulin resistance: cross sectional survey using data from the British women's heart and health study. BMJ 2002;325: 805-7. [PMC free article] [PubMed]

6. Lawlor DA, Ebrahim S, Davey Smith G. The association between components of adult height and type II diabetes and insulin resistance: British women's heart and health study. Diabetologia 2002;45: 1097-106. [PubMed]

7. Ensrud KE, Blackwell TL, Mangione CM, Bowman PJ, Whooley MA, Bauer DC, et al. Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc 2002;50: 1629-37. [PubMed]

8. British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS, 2003. (No 45.) www.bnf.org

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10. Greenland S, Drescher K. Maximum likelihood estimation of the attributable fraction from logistic models. Biometrics 1993;49: 865-72. [PubMed]

11. McIntosh S, Da Costa D, Kenny RA. Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a “syncope” clinic. Age Ageing 1993;22: 53-8. [PubMed]

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15. Department of Health. Health survey for England: cardiovascular disease. London: Stationery Office, 1999.

16. Neutel CI, Hirdes JP, Maxwell CJ, Patten SB. New evidence on benzodiazepine use and falls: the time factor. Age Ageing 1996;25: 273-78. [PubMed]

17. Cummings SR, Nevitt MC, Kidd S. Forgetting falls: the limited accuracy of recall of falls in the elderly. J Am Geriatr Soc 1988;36: 613-6. [PubMed]

18. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999;47: 850-3. [PubMed]

19. McLeod AA. Later management of documented ischaemic heart disease: secondary prevention and rehabilitation. Br Med Bull 2001;59: 113-33. [PubMed]

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