September 16, 2008, DIA DAILY NEWSLETTER reports that the Food and Drug Administration (FDA) “has approved the first anti-nausea patch for chemotherapy patients, intended to provide relief for up to five days. The patch, called Sancuso (granisetron transdermal system), is worn on the arm and delivers a widely used anti-nausea medicine, known as granisetron, through the skin.” The treatment “is expected to be available by the end of the year.”

According to MedPage Today (9/15, Peck), the FDA’s approval of Sancuso “was based on results of a 641-patient, multi-center, randomized, double-blind, double-dummy controlled phase III study, designed as a non-inferiority trial with oral granisetron as control.” In the trial, all of the “patients were undergoing chemotherapy regimens known to be associated with moderate to high risk of nausea and vomiting. The efficacy, tolerability, and safety of the transdermal system were compared with oral granisetron (two mg).”

Medscape (9/15, Barclay) added that among the 641 patients “who received moderately or highly nausea-inducing multiday chemotherapy, Sancuso met the primary endpoint of efficacy comparable to that of oral granisetron in achieving complete control of CINV [chemotherapy-induced nausea and vomiting]. This endpoint was defined as the absence of vomiting and/or retching, nausea mild or absent, and no use of rescue medication from first administration of Sancuso until 24 hours after the last day of chemotherapy.” Furthermore, “in clinical trials, the patch was generally well tolerated, with drug-related adverse reactions occurring in 8.7 percent of patients receiving Sancuso. Constipation was the most frequently reported drug-related adverse reaction. … No clinically relevant drug interactions have been reported.”

WebMD (9/15, DeNoon) explained that “Granisetron, delivered by injection or orally via tablets or solution, is sold under the brand name Kytril by Roche Pharmaceuticals. The Sancuso patch is from Scotland-based ProStrakan International.”

The BBC (9/15) reported that ProStrakan “is seeking European approval for Sancuso.” The Financial Times (9/16, O’Doherty), the U.K.’s Telegraph (9/15, Ruddick), and the U.K.’s The Herald (9/16, Williamson) also cover the story

September 15, 2008, CNN.COM — Does a test that promises to find ovarian cancer sooner really do so? Could other tests nearing the market prolong survival by getting patients the right care faster?

0A27AE02-E717-4E4B-AF7F-717A0DB4BF9B.jpgA race is on for blood tests to better detect this intractable killer, but the Food and Drug Administration is probing whether to crack down on the first one to sell.

It’s a time of both hope and confusion.

First, the question is whether testing giant LabCorp jumped the gun in selling OvaSure as an ovarian cancer screening test before researchers proved that it catches the tumor in an early, treatable stage without falsely alarming too many healthy women. A legal quirk let sales begin without formal FDA approval.

In fact, U.S. and British scientists are just beginning studies specially designed to prove whether signs of ovarian cancer can be measured reliably in blood months, even a year, before a tumor becomes life-threatening.

“You really need evidence that screening actually saves lives, or at least prolongs survival,” cautions Dr. Robert Bast Jr., an ovarian biomarker expert at M.D. Anderson Cancer Center.

While the FDA won’t discuss its ongoing probe of OvaSure, it is watching the field closely.

“It’s not a question of if, it’s a question of when the right test will come along with the right credentialing to help improve health care in this important area,” says Dr. Steven Gutman, FDA’s diagnostic testing chief.

At the same time, competing companies are seeking FDA approval for a different approach: Blood tests to help identify which women with an ovarian lump or cyst are most likely to have cancer, so they can have their crucial first surgery — the one that diagnoses malignancy — done by a specialist.

Thousands of women get cysts but only an unlucky fraction turn out to be cancer. Studies show even advanced patients can live many months longer if that very first operation is done by a gynecologic oncologist, who knows where cancer hides and how to remove pelvic lymph nodes, instead of the general surgeon most see today.

“That’s a big, big step forward for women because it allows them to get the proper care,” says Dr. Richard Moore of Brown University, who led a study of Fujirebio Diagnostics Inc.’s so-called triage test that correctly predicted cancerous cysts more than 90 percent of the time.

“It really is an unmet need,” agrees Bast.

Ovarian cancer will be diagnosed in nearly 22,000 women this year. Most see a doctor for symptoms — bloating, a swollen abdomen, pelvic pain, frequent urination — that strike after the cancer has spread, when long-term survival plummets. More than 15,000 patients die each year.

Women at high risk because of BRCA gene mutations are advised to have their ovaries removed for protection. For the general population, the goal is a blood test to detect early cancer signs such as molecules that tumor cells shed, or perhaps unusual hormone changes, without sending too many women to unnecessary surgery. In the pipeline:

• Two tumor markers, CA125 and one just approved by FDA called HE4, used to track whether chemotherapy is working or cancer is returning. A one-time CA125 test can’t screen seemingly healthy women because levels rise with benign cysts, endometriosis, even normal menstruation. But Fujirebio’s triage test uses HE4 and CA125 to assess who most likely has a benign cyst and whose may be cancer.

• LabCorp in June began marketing to high-risk women a screening test developed by Yale University, under a law that allows a single laboratory to offer testing without FDA review. Yale researchers used OvaSure on blood samples stored from cancer patients and healthy women, and found it correctly identified cancer 95 percent of the time with few false alarms. But specialists say that doesn’t prove OvaSure can detect when cancer is forming — just that it spotted tumors in the already diagnosed few with early stage disease.

“We believe you are offering a high risk test that has not received adequate clinical validation and may harm the public health,” the FDA warned LabCorp last month.

The FDA several years ago forced a similarly marketed ovarian test off the market. LabCorp spokesman Eric Lindblom wouldn’t disclose results of a recent FDA meeting, but said Yale is working to validate OvaSure and “we’re continuing to offer the test at this time.”

• Tracking seemingly healthy women well before their cancer is diagnosed is the only way to prove a test finds cancer early, says Dr. Michael Birrer of the National Cancer Institute — work just beginning.

Dr. Nicole Urban of Seattle’s Fred Hutchinson Cancer Center is heading a multi-hospital test of blood stored a full year before 120 women were diagnosed with ovarian cancer, to see which biomarkers are most promising.

“The thing we did not know is how early these markers give a signal,” said Urban, whose hunt is joined by Yale, M.D. Anderson and other leading ovarian cancer centers.

Also, British researchers have enrolled 200,000 women in a study to see if annual CA125 testing plus transvaginal ultrasounds will spot simmering tumors. The idea: High jumps in CA125 levels might give a better signal than a one-time test.


Ovarian Cancer


Women have two ovaries, one on each side of the uterus. The ovaries — each about the size of an almond — produce eggs (ova) as well as the female sex hormones estrogen and progesterone. Ovarian cancer is a disease in which normal ovarian cells begin to grow in an uncontrolled, abnormal manner and produce tumors in one or both ovaries.

According to the American Cancer Society, ovarian cancer ranks fifth in cancer deaths among women. It’s estimated that about 20,000 women in the United States will develop ovarian cancer this year. About 15,000 deaths from ovarian cancer will occur in American women during that same time frame.

Your chances of surviving ovarian cancer are better if the cancer is found early. But because the disease is difficult to detect in its early stage, only about 20 percent of ovarian cancers are found before tumor growth has spread into adjacent tissues and organs beyond the ovaries. Most of the time, the disease has already advanced before it’s diagnosed.

Until recently, doctors thought that early-stage ovarian cancer rarely produced any symptoms. But new evidence has shown that most women may have signs and symptoms even in the early stages of the disease. Being aware of them may lead to earlier detection.

Signs and symptoms

Symptoms of ovarian cancer are nonspecific and mimic those of many other more common conditions, including digestive and bladder disorders. It isn’t unusual for a woman with ovarian cancer to be diagnosed with another condition before finally learning she has cancer. The key seems to be persistent or worsening signs and symptoms. With most digestive disorders, symptoms tend to come and go, or they occur in certain situations or after eating certain foods. With ovarian cancer, there’s typically little fluctuation — symptoms are constant and gradually worsen.

Recent studies have shown that women with ovarian cancer are more likely than are other women to consistently experience the following symptoms:

* Abdominal pressure, fullness, swelling or bloating
* Urinary urgency
* Pelvic discomfort or pain

Additional signs and symptoms that women with ovarian cancer may experience include:

* Persistent indigestion, gas or nausea
* Unexplained changes in bowel habits, including diarrhea or constipation
* Changes in bladder habits, including a frequent need to urinate
* Loss of appetite
* Unexplained weight loss or gain
* Increased abdominal girth or clothes fitting tighter around your waist
* Pain during intercourse (dyspareunia)
* A persistent lack of energy
* Low back pain

Doctors can usually diagnose ovarian cancer within three months of women first noticing symptoms, but sometimes it may take six months or longer before a diagnosis can be made.


An ovarian tumor is a growth of abnormal cells that may be either noncancerous (benign) or cancerous (malignant). Although benign tumors are made up of abnormal cells, these cells don’t spread to other body tissues (metastasize). Ovarian cancer cells metastasize in one of two ways. Most often, they spread directly to adjacent tissue or organs in the pelvis and abdomen. Rarely, they spread through your bloodstream or lymph channels to other parts of your body.

The causes of ovarian cancer remain unknown. Some researchers believe it has to do with the tissue-repair process that follows the monthly release of an egg through a tiny tear in an ovarian follicle (ovulation) during a woman’s reproductive years. The formation and division of new cells at the rupture site may set up a situation in which genetic errors occur. Others propose that the increased hormone levels before and during ovulation may stimulate the growth of abnormal cells.

Three basic types of ovarian tumors exist, designated by where they form in the ovary. They include:

* Epithelial tumors. About 85 percent to 90 percent of ovarian cancers develop in the epithelium, the thin layer of tissue that covers the ovaries. This form of ovarian cancer generally occurs in postmenopausal women.
* Germ cell tumors. These tumors occur in the egg-producing cells of the ovary and generally occur in younger women.
* Stromal tumors. These tumors develop in the estrogen- and progesterone-producing tissue that holds the ovary together.

Risk factors

Several factors may increase your risk of ovarian cancer. Having one or more of these risk factors doesn’t mean that you’re sure to develop ovarian cancer, but your risk may be higher than that of the average woman. These risk factors include:

* Inherited gene mutations. The most significant risk factor for ovarian cancer is having an inherited mutation in one of two genes called breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2). These genes were originally identified in families with multiple cases of breast cancer, which is how they got their names, but they’re also responsible for about 5 percent to 10 percent of ovarian cancers. You’re at particularly high risk of carrying these types of mutations if you’re of Ashkenazi Jewish descent. Another known genetic link involves an inherited syndrome called hereditary nonpolyposis colorectal cancer (HNPCC). Individuals in HNPCC families are at increased risk of cancers of the uterine lining (endometrium), colon, ovary, stomach and small intestine. Risk of ovarian cancer associated with HNPCC is lower than is that of ovarian cancer associated with BRCA mutations.
* Family history. Sometimes, ovarian cancer occurs in more than one family member but isn’t the result of any known inherited gene alteration. Having a family history of ovarian cancer increases your risk of the disease, but not to the same degree as does having an inherited genetic defect. If you have one first-degree relative — a mother, daughter or sister — with ovarian cancer, your risk of developing the disease is 5 percent over your lifetime.
* Age. Ovarian cancer most often develops after menopause. Your risk of ovarian cancer increases with age through your late 70s. Although most cases of ovarian cancer are diagnosed in postmenopausal women, the disease also occurs in premenopausal women.
* Childbearing status. Women who have had at least one pregnancy appear to have a lower risk of developing ovarian cancer. Similarly, the use of oral contraceptives appears to offer some protection against ovarian cancer.
* Infertility. If you’ve had trouble conceiving, you may be at increased risk. Although the link is poorly understood, studies indicate that infertility increases the risk of ovarian cancer, even without use of fertility drugs. The risk appears to be highest for women with unexplained infertility and for women with infertility who never conceive. Research in this area is ongoing.
* Ovarian cysts. Cyst formation is a normal part of ovulation in premenopausal women. However, cysts that form after menopause have a greater chance of being cancerous. The likelihood of cancer increases with the size of the growth and with age.
* Hormone replacement therapy (HRT). Findings about the possible link between postmenopausal use of the hormones estrogen and progestin and risk of ovarian cancer have been inconsistent. Some studies indicate a slightly increased risk of ovarian cancer in women taking estrogen after menopause, but other studies show no significant increase in risk. However, in a large study published in the Journal of the National Cancer Institute in October 2006, researchers report that women who haven’t had a hysterectomy and who used menopausal hormone therapy for five or more years face a significantly increased risk of ovarian cancer.
* Obesity in early adulthood. Studies have suggested that women who are obese at age 18 are at increased risk of developing ovarian cancer before menopause. Obesity may also be linked to more aggressive ovarian cancers, which can result in a shorter time to disease relapse and a decrease in the overall survival rate.

When to seek medical advice

See your doctor if you have persistent swelling, bloating, pressure or pain in your abdomen or pelvis. If you’ve already seen a doctor and received a diagnosis other than ovarian cancer, but you’re not getting relief from the treatment, schedule a follow-up visit with your doctor or get a second opinion. Make sure that a pelvic exam is a part of your evaluation.

If you have a history of ovarian cancer in your family, strongly consider seeing a doctor trained to detect and care for ovarian cancer patients so that you can talk about screening and treatment options while you are disease-free.

If your primary care physician suspects you have ovarian cancer, he or she may refer you to a specialist in female reproductive cancers (gynecologic oncologist), or you may ask for a referral yourself. A gynecologic oncologist is an obstetrician and gynecologist (OB-GYN) who has additional training in the diagnosis and treatment of ovarian and other gynecologic cancers.

Screening and diagnosis

Screening for a cancer means that you have no symptoms of the disease, and testing is done in an effort to find the disease in a very early, curable stage. To be effective, screening tests must be able to reliably detect the presence of early-stage disease, yet not lead to an excess number of false-positive results — tests that suggest that cancer is present, when in fact there is no cancer. Effective screening tests are available for several common cancers, including: mammography for breast cancer, the Pap test for cervical cancer, colonoscopy for colon cancer, and the prostate-specific antigen test and rectal exam for prostate cancer.

But no standardized screening test exists to reliably detect ovarian cancer. Researchers haven’t yet found a screening tool that’s sensitive enough to detect ovarian cancer in its early stages and specific enough to distinguish ovarian cancer from other, noncancerous conditions. Doctors don’t recommend routine screening for women at average risk of ovarian cancer.

For high-risk women, experts don’t agree on exactly what to do for screening, when to do it or if it should even be done at all. If you’re at high risk of ovarian cancer, you need to have a careful discussion with your doctor about the risks and benefits of undergoing screening tests. While you may wonder what harm could come from a screening test, know that these tests can lead to unnecessary operations or other procedures that have significant side effects. In one study of women at high risk of ovarian cancer, researchers discovered that use of screening tests led to 20 operations on women, only one of whom was found to have cancer — metastatic breast cancer, not ovarian cancer.

If your doctor suspects your symptoms suggest the presence of ovarian cancer, he or she may recommend one or more of the following tests:

* Pelvic examination. Your doctor examines your vagina, uterus, rectum and pelvis, including your ovaries, for masses or growths. If you’ve had your uterus removed (hysterectomy) but still have your ovaries, continue getting regular pelvic exams.
* Ultrasound. Ultrasound uses high-frequency sound waves to produce images of the inside of the body. Pelvic ultrasound provides a safe, noninvasive way to evaluate the size, shape and configuration of the ovaries. If a mass is found, however, ultrasound can’t reliably differentiate a cancerous growth from one that’s not cancerous. Ultrasound can also detect fluid in your abdominal cavity (ascites), a possible sign of ovarian cancer. Because ascites develops in many conditions other than ovarian cancer, however, its presence necessitates more testing.
* CA 125 blood test. CA 125 is a protein made by your body in response to many different conditions. Many women with ovarian cancer have abnormally high levels of CA 125 in their blood. However, a number of noncancerous conditions also cause elevated CA 125 levels, and many women with early-stage ovarian cancer have normal CA 125 levels. Because of this lack of specificity, the CA 125 test isn’t used for routine screening in average-risk women and is of uncertain benefit in high-risk women.

Other diagnostic tests may include computerized tomography (CT) and magnetic resonance imaging (MRI), which both provide detailed, cross-sectional images of the inside of your body. Your doctor also may order a chest X-ray to determine if cancer has spread to the lungs or to the pleural space surrounding the lungs, where fluid can accumulate. If fluid is present, a needle may be inserted into the space to remove it. The fluid is then checked in the laboratory for cancer cells.

If these tests suggest ovarian cancer, you’ll need an operation to confirm the diagnosis. In a surgical procedure called laparotomy, a gynecologic oncologist makes an incision in your abdomen and explores your abdominal cavity to determine whether cancer is present. The surgeon may collect samples of abdominal fluid and remove an ovary for examination by a pathologist.

In certain cases, a less invasive surgical procedure called laparoscopy may be used. Laparoscopy requires only a couple of small incisions, through which a lighted instrument is inserted, along with small tools used to perform the surgery. Laparoscopy may be used if a surgeon wants to remove a tissue mass to determine whether it’s cancerous before proceeding with a more invasive operation.

If ovarian cancer is confirmed, the surgeon and pathologist identify the type of tumor and determine whether the cancer has spread. This will help determine the stage of the disease. The surgeon usually will then need to extend the incision so that he or she can perform a more extensive operation to remove as much cancer as possible. It’s important that this type of surgery be performed by a doctor specifically trained to treat gynecologic cancers.

Before you have a diagnostic operation, talk with your doctor about what your treatment options will be if you turn out to have a noncancerous abnormality on your ovary. If you’re near or past menopause, your doctor may recommend removing both of your ovaries to decrease your risk of ovarian cancer.

Stages of ovarian cancer
Ovarian cancer is classified in stages I through IV, with stage I being the earliest and stage IV, the most advanced. Staging is determined at the time of surgical evaluation of the disease:

* Stage I. Ovarian cancer is confined to one or both ovaries.
* Stage II. Ovarian cancer has spread to other locations in the pelvis such as the uterus or fallopian tubes.
* Stage III. Ovarian cancer has spread to the lining of the abdomen (peritoneum) or to the lymph nodes within the abdomen. This is the most common stage of disease identified at the time of diagnosis.
* Stage IV. Ovarian cancer has spread to organs beyond the abdomen.


Treatment of ovarian cancer usually involves a combination of surgery and chemotherapy.

If you want to preserve the option to have children and if your tumor is discovered early, your surgeon may remove only the involved ovary and its fallopian tube. However, this situation is rare, and subsequent chemotherapy can cause infertility. But some women in these circumstances have gone on to successfully bear children after treatment.

The vast majority of women with ovarian cancer require a more extensive operation that includes removing both ovaries, fallopian tubes, and the uterus as well as nearby lymph nodes and a fold of fatty abdominal tissue known as the omentum, where ovarian cancer often spreads.

During this procedure, your surgeon also removes as much cancer as possible from your abdomen (surgical debulking). Ideally, less than a total of 1 cubic centimeter of tumor matter remains in your abdominal cavity after surgery (optimal debulking). This may involve removing part of your intestines.

In addition, your surgeon will take samples of tissue and fluid from your abdomen to examine for cancer cells. This evaluation is critical in identifying the stage of your disease and determining if you need additional therapy.

After surgery, you’ll most likely be treated with chemotherapy — drugs designed to kill any remaining cancer cells. The initial regimen for ovarian cancer includes the combination of carboplatin (Paraplatin) and paclitaxel (Taxol) injected into the bloodstream (intravenous administration). Extensive clinical trials prove that this combination is the most effective, though studies continue to look for ways to improve on it. The carboplatin-paclitaxel combination reduces tumor volume in about 80 percent of women with newly diagnosed ovarian cancer. Studies have also shown that the combination results in longer survival, compared with that of previously used chemotherapy drugs and combinations.

A more intensive regimen has recently been shown to improve survival in women with advanced ovarian cancer by combining standard intravenous chemotherapy with chemotherapy injected directly into the abdominal cavity through a catheter placed at the time of the initial operation. This intra-abdominal infusion exposes hard-to-reach cancer cells to higher levels of chemotherapy than can be reached intravenously.

This treatment typically involves six rounds of both intravenous and abdominal chemotherapy. Side effects — including abdominal pain, nausea, vomiting and infection — may leave many women unable to complete a full course of treatment or others to forego treatment entirely. But even an incomplete course of this treatment may help women live longer.

Other treatments being explored include new chemotherapy drugs, vaccines, gene therapy and immunotherapy, which boosts the body’s own immune system to help combat cancer. The discovery of genes that are mutated in ovarian cancer also may lead to the development of drugs that specifically target the function of these genes.


Several factors appear to reduce the risk of ovarian cancer. They include:

* Oral contraception (birth control pills). Compared with women who’ve never used them, women who use oral contraceptives for three years or more reduce their risk of ovarian cancer by 30 percent to 50 percent.
* Pregnancy and breast-feeding. Having at least one child lowers your risk of developing ovarian cancer. Breast-feeding a child for a year or longer also may reduce your risk of ovarian cancer.
* Tubal ligation or hysterectomy. The Nurses’ Health Study, which followed thousands of women for 20 years, found a substantial reduction in ovarian cancer risk in women who had had tubal ligations. The procedure also has been shown to reduce ovarian cancer risk among women with mutations in the BRCA1 gene. How the procedure reduces risk is uncertain. The Nurses’ Health Study also indicated that having a hysterectomy may reduce ovarian cancer risk, but not by as much as does tubal ligation.

Women who are at very high risk of developing ovarian cancer may elect to have their ovaries removed as a means of preventing the disease. This surgery, known as prophylactic oophorectomy, is recommended primarily for women who’ve tested positive for a BRCA gene mutation or women who have a strong family history of breast and ovarian cancers, even if no genetic mutation has been identified.

Studies indicate that prophylactic oophorectomy lowers ovarian cancer risk by up to 95 percent, and reduces the risk of breast cancer by up to 50 percent, if the ovaries are removed before menopause. Prophylactic oophorectomy reduces, but doesn’t completely eliminate, ovarian cancer risk. Because ovarian cancer usually develops in the thin lining of the abdominal cavity that covers the ovaries, women who have had their ovaries removed can still get a similar but less common form of cancer called primary peritoneal cancer.

In addition, prophylactic oophorectomy is controversial because it induces early menopause, which in itself may have a negative impact on your health, including an increased risk of osteoporosis, heart disease and other conditions. If you’re considering having this procedure done, be sure to discuss the pros and cons with your doctor.


Eating well, managing stress and exercising are ways to promote your overall health and cope with any form of cancer.

Eating well
Good nutrition is especially important for people undergoing cancer treatment. But eating well can be difficult for a time if your treatment includes chemotherapy or radiation therapy. You may feel nauseated or lose your appetite, and foods may taste bland or unpleasant. You may find that the last thing you want to do is plan meals.

Even so, eating well during cancer treatment can help you maintain your stamina and your ability to cope with the side effects of treatments. Good nutrition may also help you prevent infections and remain more active.

Remember these strategies for eating well when you don’t feel well:

* Eat protein-rich foods. Foods high in protein can help build and repair body tissues. Choices include eggs, yogurt, cottage cheese, peanut butter, poultry and fish. Kidney beans, chickpeas and black-eyed peas also are good sources of protein, especially when combined with rice, corn or bread.
* Keep an open mind about the foods you might eat. Something that is unappealing today might taste better to you next week.
* When you do feel well, make the most of it. Eat as many healthy foods as you can. Prepare meals that you can easily freeze and reheat. Also look for low-fat frozen dinners and other prepared foods.
* Give meals a pleasant atmosphere. Whenever possible, eat at a table set with attractive dishes and flowers.
* Pack calories into the foods you eat. For example, spread butter, jam or honey on bread. Sprinkle foods with chopped nuts.
* Eat smaller amounts of food more frequently. If you can’t face the thought of a large meal, try eating small amounts of food more often. Keep fruits and vegetables handy for snacking.
* Stay active. Even if you don’t feel well, try to stay physically active. A short walk or climbing the stairs can keep your muscles from deteriorating due to lack of use.

Managing stress
Methods for reducing muscle tension can help you manage stress. One simple and powerful technique is to close your eyes and notice your breathing. Pay attention to each inhalation and exhalation. Your breathing will become slower and deeper, promoting relaxation. Another technique is to lie down, close your eyes and mentally scan your entire body for any points of tension.

In addition, activities that require repetitive movement, such as swimming, can produce a mental state similar to that achieved with meditation. The same is true of yoga and other stretching exercises.

Your doctor may have more specific suggestions about how to best care for yourself before, during and after treatment for ovarian cancer.

Coping skills

A diagnosis of cancer can be extremely challenging. Even when a full recovery is likely, you may worry about a recurrence of the disease. But no matter what your concerns or prognosis, you’re not alone. Here are some strategies and resources that may make dealing with cancer easier:

* Know what to expect. Find out everything you want to know about your cancer — such as type, stage, treatment options and side effects. The more you understand, the more active you can be in your own care. In addition to talking with your doctor, look for information at your local library and on Web sites affiliated with reputable organizations.
* Be proactive. Discuss with your doctor, family and those you rely on for support how you want to approach decision making. For instance, some women prefer to get all the information and make treatment-related decisions for themselves. Others would rather have another trusted person, such as a family member, friend, doctor or member of their health care team, take the lead in decision making. And some women blend these two approaches to find some middle ground. Use the decision-making approach that feels best for you.
* Maintain a strong support system. Strong relationships can play an important role in surviving cancer. Although friends and family can be your best allies, they may sometimes have trouble dealing with your illness. When this is the case, the concern and the understanding of a formal support group or other cancer survivors can be especially helpful. Although support groups aren’t for everyone, they can be a good source of practical information. You may also find that you develop deep and lasting bonds with people who are going through the same things you are. Support groups for the families of cancer survivors also are available.
* Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. But don’t choose goals you can’t possibly reach. You may not be able work a 50-hour week, for example, but you may be able to work at least half-time. In fact, many people find that continuing to work is helpful.
* Take time for yourself. Eating well, relaxing and getting enough rest can help combat the stress and fatigue of cancer. Also, cut back on time commitments and plan ahead for times when you may need more rest.

John Kleber

some invaders can even spur the evolution of new diversity

By Carl Zimmer, September 15, 2008, The New York Times – New Zealand is home to 2,065 native plants found nowhere else on Earth. They range from magnificent towering kauri trees to tiny flowers that form tightly packed mounds called vegetable sheep.

When Europeans began arriving in New Zealand, they brought with them alien plants — crops, garden plants and stowaway weeds. Today, 22,000 non-native plants grow in New Zealand. Most of them can survive only with the loving care of gardeners and farmers. But 2,069 have become naturalized: they have spread out across the islands on their own. There are more naturalized invasive plant species in New Zealand than native species.

It sounds like the makings of an ecological disaster: an epidemic of invasive species that wipes out the delicate native species in its path. But in a paper published in August in The Proceedings of the National Academy of Sciences, Dov Sax, an ecologist at Brown University, and Steven D. Gaines, a marine biologist at the University of California, Santa Barbara, point out that the invasion has not led to a mass extinction of native plants. The number of documented extinctions of native New Zealand plant species is a grand total of three.

Exotic species receive lots of attention and create lots of worry. Some scientists consider biological invasions among the top two or three forces driving species into extinction. But Dr. Sax, Dr. Gaines and several other researchers argue that attitudes about exotic species are too simplistic. While some invasions are indeed devastating, they often do not set off extinctions. They can even spur the evolution of new diversity.

“I hate the ‘exotics are evil’ bit, because it’s so unscientific,” Dr. Sax said.

Dr. Sax and his colleagues are at odds with many other experts on invasive species. Their critics argue that the speed with which species are being moved around the planet, combined with other kinds of stress on the environment, is having a major impact.

There is little doubt that some invasive species have driven native species extinct. But Dr. Sax argues that they are far more likely to be predators than competitors.

In their new paper, Dr. Sax and Dr. Gaines analyze all of the documented extinctions of vertebrates that have been linked to invasive species. Four-fifths of those extinctions were because of introduced predators like foxes, cats and rats. The Nile perch was introduced into Lake Victoria in 1954 for food. It then began wiping out native fish by eating them.

“If you can eat something, you can eat it everywhere it lives,” Dr. Sax said.

But Dr. Sax and Dr. Gaines argue that competition from exotic species shows little sign of causing extinctions. This finding is at odds with traditional concepts of ecology, Dr. Sax said. Ecosystems have often been seen as having a certain number of niches that species can occupy. Once an ecosystem’s niches are full, new species can take them over only if old species become extinct.

But as real ecosystems take on exotic species, they do not show any sign of being saturated, Dr. Sax said. In their paper, Dr. Sax and Dr. Gaines analyze the rise of exotic species on six islands and island chains. Invasive plants have become naturalized at a steady pace over the last two centuries, with no sign of slowing down. In fact, the total diversity of these islands has doubled.

Fish also show this pattern, said James Brown of the University of New Mexico. He said that whenever he visits a river where exotic fish have been introduced, “I ask, ‘Have you seen any extinctions of the natives?’ ” “The first response you get is, ‘Not yet,’ as if the extinction of the natives is an inevitable consequence. There’s this article of faith that the net effect is negative.”

Dr. Brown does not think that faith is warranted. In Hawaii, for example, 40 new species of freshwater fish have become established, and the 5 native species are still present. Dr. Brown and his colleagues acknowledge that invasive species can push native species out of much of their original habitat. But they argue that native species are not becoming extinct, because they compete better than the invasive species in certain refuges.

These scientists also point out that exotics can actually spur the evolution of new diversity. A North American plant called saltmarsh cordgrass was introduced into England in the 19th century, where it interbred with the native small cordgrass. Their hybrid offspring could not reproduce with either original species, producing a new species called common cordgrass.

Long before humans moved plants around, many plants hybridized into new species by this process. “Something like a third of the plant species you see around you formed that way,” Dr. Sax said.

Biological invasions also set off bursts of natural selection. House sparrows, for example, have moved to North America from Europe and have spread across the whole continent. “Natural selection will start to change them,” Dr. Sax said. “If you give that process enough time, they will become new species.”

“The natives themselves are also likely to adapt,” Dr. Sax added. Some of the fastest rates of evolution ever documented have taken place in native species adapting to exotics. Some populations of soapberry bugs in Florida, for example, have shifted from feeding on a native plant, the balloon vine, to the goldenrain tree, introduced from Asia by landscapers in the 1950s. In five decades, the smaller goldenrain seeds have driven the evolution of smaller mouthparts in the bugs, along with a host of other changes.

In Australia, the introduction of cane toads in the 1930s has also spurred evolution in native animals. “Now that you have cane toads in Australia, there’s a strong advantage for snakes that can eat them,” said Mark Vellend, of the University of British Columbia. Cane toads are protected by powerful toxins in their skin that can kill predators that try to eat them. But in parts of the country where the toads now live, black snakes are resistant to the toxins in their skin. In the parts where the toad has yet to reach, the snakes are still vulnerable.

Dr. Brown argues that huge negative effects of invasions are not documented in the fossil record, either. “You see over and over and over again that this is never the case,” he said. Species have invaded new habitats when passageways between oceans have opened up or when continents have collided.

“The overall pattern almost always is that there’s some net increase in diversity,” Dr. Brown said. “That seems to be because these communities of species don’t completely fill all the niches. The exotics can fit in there.”

In a recent paper in the journal Science, Peter Roopnarine of the California Academy of Sciences and Geerat Vermeij of the University of California, Davis, looked at the history of invasions among species of mollusks, a group that includes mussels, clams and whelks. About 3.5 million years ago, the mollusks of the North Pacific staged a major invasion of the North Atlantic. Before then, the Arctic Ocean had created a barrier, because the mussels could not survive in the dark, nutrient-poor water under the ice.

A period of global warming made the Arctic less forbidding. Yet the migration did not lead to a significant drop in the diversity of the Atlantic native mussels. Instead, the Atlantic’s diversity rose. Along with the extra exotic species, new species may have arisen through hybridization.

The Arctic Ocean is now warming again, this time because of human activity. Computer projections indicate it will become ice-free at least part of the year by 2050. Dr. Roopnarine and Dr. Vermeij predicted that today’s mollusks would make the same transoceanic journey they did 3.5 million years ago. They also expect the invasion to increase, rather than decrease, diversity.

But critics, including Anthony Ricciardi of McGill University in Montreal, argue that today’s biological invasions are fundamentally different from those of the past.

“What’s happening now is a major form of global change,” Dr. Ricciardi said. “Invasions and extinctions have always been around, but under human influence species are being transported faster than ever before and to remote areas they could never reach. You couldn’t get 35 European mammals in New Zealand by natural mechanisms. They couldn’t jump from one end of the world to another by themselves.”

It is estimated that humans move 7,000 species a day. In the process, species are being thrown together in combinations that have never been seen before. “We’re seeing the assembly of new food webs,” said Phil Cassey of the University of Birmingham in England. Those new combinations may allow biological invasions to drive species extinct in unexpected ways.

Botulism, for example, is killing tens of thousands of birds around the Great Lakes. Studies indicate that two invasive species triggered the outbreak. The quagga mussel, introduced from Ukraine, filters the water for food, making it clearer. The sunlight that penetrates the lakes allows algae to bloom, and dead algae trigger an explosion of oxygen-consuming bacteria. As the oxygen level drops, the botulism-causing bacteria can multiply. The quagga mussels take up the bacteria, and they in turn are eaten by another invasive species: a fish known as the round goby. When birds eat round gobies, they become infected and die.

“If you pour on more species, you don’t just increase the probability that one is going to arrive that’s going to have a high impact,” Dr. Ricciardi said. “You also get the possibility of some species that triggers a change in the rules of existence.”

Dr. Ricciardi argues that biological invasions are different today for another reason: they are occurring as humans are putting other kinds of stress on ecosystems. “Invasions will interact with climate change and habitat loss,” he said. “. We’re going to see some unanticipated synergies.”

Both sides agree, however, that decisions about invasive species should be based on more than just a tally of positive and negative effects on diversity. Invasive weeds can make it harder to raise crops and graze livestock, for example. The Asian long-horned beetle is infesting forests across the United States and is expected to harm millions of acres of hardwood trees. Zebra mussels have clogged water supply systems in the Midwestern United States. Exotic species can also harm humans’ health. “West Nile virus, influenza — these things are invasions,” Dr. Ricciardi said.

On the other hand, some invasive species are quite important. In the United States, many crops are pollinated by honeybees originally introduced from Europe.

“It’s not that this is all good or all bad, and I’m not sure science should be the arbiter,” Dr. Brown said. “Placing values on these things is the job of society as a whole.”