Don Vaughan

George Sheehan, 77, of Diamond Springs, California, enjoyed excellent health until he was stricken with a persistent sore throat in 2016. His ear, nose and throat specialist diagnosed the problem as acid reflux, but after months of treatment with traditional therapies brought no relief, Sheehan sought a second opinion from his gastroenterologist. Sheehan was referred to the University of California, Davis, where a biopsy confirmed that the retired manager had stage 4 squamous cell carcinoma of the larynx.

“They sat me down, explained I had cancer and said it would be best if they removed my larynx,” Sheehan recalls. “The cancer was isolated so I didn’t need chemo- therapy or radiation. I was very fortunate.”

Sheehan received a voice prosthesis and met regularly with a speech therapist. At the same time, Sheehan’s wife, Paula, also a cancer survivor, learned from visiting nurses and instructional videos how to help her husband keep his stoma clean and regain his ability to speak. When Sheehan was well again, the couple celebrated with a cross-country motorcycle trip.

George and Paula Sheehan celebrated his improved health with a cross-country motorcycle trip.

Despite losing his larynx, Sheehan was luckier than many patients with cancer his age. Geriatric patients with cancer, defined as those 65 and older, often have health and other issues that can make cancer treatment difficult. Caring for this population has always been a challenge, but cancer care specialists are making strides to ensure that they receive the same level of support provided to younger patients.

Cancer can strike at any age but is most prevalent among adults as they age. According to a 2008 study published in the journal Cancer, about 60% of cancer incidence and 70% of cancer mortality occurs among adults aged 65 and older. This also happens to be the fastest-growing population in the United States, notes the National Cancer Institute, with a projected population of 84 million by 2050.

As patients age, they can be divided into three groups, says Dr. Stuart Lichtman, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York. The first is the well elderly, who tend to be the minority. This is followed by the vulnerable elderly, who can be well functioning and independent but have other medical issues that make them vulnerable to side effects of cancer treatment. The third group is the frail elderly, such as patients in nursing homes. Some frail elderly patients are strong enough to receive treatment for their cancer, Lichtman says, but others may be so vulnerable that treatment is not even a consideration.

“Medicine is never black and white,” Lichtman notes. “You can’t just look at age. You have to look at the whole patient. Geriatric oncology is ‘the ultimate in personalized medicine’ because everyone is a little different. Everyone at that point in their life has had issues in the past and it affects treatment decisions as well as wishes and goals.”

Only within the past few decades has a greater focus been placed on the unique needs of aging patients with cancer, thanks to the efforts of advocates such as medical sociologist Rosemary Yancik, who served many years at the National Institutes of Health and was instrumental in founding the International Society of Geriatric Oncology in 2000. One of the most important concerns for advocates such as Yancik has been the lack of patients 65 and older enlisted in clinical drug trials because of safety concerns.

“In the early days of cancer treatment, the thinking was that people above the age of 65 would not be able to tolerate treatment, so the upper age was 65 for clinical trials,” notes Dr. Martine Extermann, program leader in the senior adult oncology program at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. “Dr. Yancik pushed for programs designed to help older cancer patients, and one of the first in the United States was here at Moffitt.”

Sheehan's wife, Paula, took care of him when he came home from the hospital, which she says was challenging at times.

A lack of aging trial participants can have serious consequences in cancer treatment, says Dr. Supriya Mohile, a geriatric oncologist at the University of Rochester Cancer Center in New York. “The challenge for us as oncologists is that data regarding the safety and efficacy of therapeutics comes from clinical trials that do not include older adults to the prevalence they have in the community,” she explains. “The therapies we have are tested on patients who are younger and in better health. When we see older adults who may have other health problems, we often don’t know how to appropriately manage that patient because we don’t have the data.”

Thankfully, attitudes regarding the inclusion of aging patients in clinical trials are starting to shift. The Cancer and Aging Research Group, in collaboration with the National Institute on Aging and the National Cancer Institute, reviewed gaps in knowledge about the care of patients age 65 and older with cancer and developed a series of recommendations to improve their participation. They include the following:

design trials specific to this patient population;

modify trial designs to collect more data on aging patients;

leverage population cohort studies to answer commonly posed questions in geriatric oncology regarding the feasibility, dosing and toxicity of a selected regimen;

conduct concurrent differential dosing trials for these patients; and

Ed Cutler, 75, of Tampa, Florida, after standard-of-care chemotherapy for 16 months, participated in two separate phase 1 immunotherapy trials as part of his treatment for lung cancer with metastases to the liver. The first drug combo — Imfinzi (durvalumab) and tremelimumab, two drugs known as checkpoint inhibitors, beginning in 2015 — reduced the size of the tumor in Cutler’s lung by 70% but side effects including severe colitis forced him to stop after seven months. A year later, Cutler began receiving taminadenant, another immunotherapy drug known as an adenosine receptor antagonist, in a phase 1 trial conducted at the Moffitt Cancer Center, again with positive results.

“I’m still an active participant of the trial and have been stable since early 2017,” Cutler says. “I am not cancer free. There is still something there, but it is not growing and it’s not getting any smaller. The treatment appears to be keeping my cancer stable.”

Cutler says that, to the best of his knowledge, his age was never considered a factor by his care team, likely because he was in relatively good physical health at the time with no comorbidities.

But that’s not the case for the majority of aging patients with cancer. Comorbidities tend to become more common with age and are a very important factor when developing a treatment plan. Especially concerning are illnesses that can negatively affect treatment and recovery such as obesity, diabetes, kidney disease, liver disease and heart issues.

“From a physiologic point of view, 20-year-olds are essentially the same. Everyone is healthy with no other diseases,” Extermann explains. “That changes as we get into our 70s and 80s. We need to understand the disease, but in addition, we need a knowledge of the patient that is much deeper than you would have for younger patients. We need to evaluate which diseases they have as well as their function and reserve, which is their capacity to rebound.”

One of the most useful tools available to geriatric oncologists is the comprehensive geriatric assessment (CGA), which helps determine if a patient will benefit from treatment or would be better off with palliative care. The CGA evaluates physical functioning, comorbid conditions, cognitive performance, psychological and nutritional status, social support, current medications and the presence of geriatric syndromes.

“With some patients, the screening may tell us that the patient is really very fit and should receive a full treatment,” Lichtman notes. “Another person may look pretty good, but when you start looking at their function, you discover all kinds of vulnerabilities, and if you start treatment with a full-dose regimen, you are going to harm that patient. We have to modify the dose and use a lighter treatment for the patient to get the best benefit.”

Ed Cutler believes his age was not taken into consideration by his care team because of his relatively good health.

In a trial conducted by the University of Rochester Cancer Center, the CGA was found to improve care delivery and patient/caregiver satisfaction, Mohile reports. A second trial found that the tool also improves decision-making and reduces cancer treatment toxicity.

“We need to learn how to implement the comprehensive geriatric assessment better and make patients and care- givers aware of it,” says Mohile. “If patients demand this evidence-based practice of their doctors, practices will adopt it more.”

Home care — both during and after treatment — can present its own challenges for aging patients with cancer. Many require continued support from their medical team, which may include a home nurse, speech therapist, physical therapist, nutritionist, wound care specialist, social worker and others. However, daily assistance typically is provided by family and friends, which can result in caregiver burnout.

“Just because a patient is married, oncologists shouldn’t assume they have a caregiver because the spouse may be in worse condition than the patient,” Extermann says. “You have to ask patients about their arrangements.”

“Our system is not a good one for caregivers,” Mohile acknowledges. “We barely address caregiver needs in our clinical encounters, and there is not a lot of support for care- givers in general. This can affect the patient. If the caregiver is stressed or has their own health needs that are being affected by caregiving, the patient is not going to do well. We need to think about them as a team.”

Paula Sheehan did all she could to meet her husband’s care needs when he returned home from the hospital. Yet despite the support she received from nurses and others, she found the experience emotionally stressful. “I took it upon myself,” she says. “You have to learn how to care for your spouse when they get home, and it’s a shock, really. You have a lot on your shoulders. It was difficult, but we got through it together. I’m really proud of him.”

"I am not cancer free. There is still something there, but it is not growing and it's not getting any smaller." - Ed Cutler

Numerous organizations provide resources for home caregivers including the American Cancer Society, the Cancer and Aging Research Group, the American Society of Clinical Oncology, Susan G. Komen for the Cure, the LUNGevity Foundation, the GO2 Foundation for Lung Cancer and the National Cancer Institute.

Aging patients are encouraged to be their own advocates and not hesitate to ask questions about their treatment options, goals and more. “One important question patients should ask is, what is the evidence for this treatment plan for patients like me? The doctor should be honest regarding the available data,” says Mohile.

Another essential question is how a particular treatment will affect the patient’s ability to function, Extermann adds. “Function matters a lot to older patients,” she notes. “Everyone wants to live longer but no one wants to grow old.”

Before surgery, patients and caregivers should look into appropriate support groups at their local hospital or cancer organization, Paula Sheehan suggests. “That was very helpful to us both,” she says. “Speaking with other laryngectomy patients before and after surgery helped us know what to expect.”

Cutler also encourages patients 65 years and older to talk not only to their medical care team but also to other patients with cancer who have been through it. “I think they are more valuable than anybody,” he notes. “A connection to other patients through the LUNGevity Foundation helped me personally and really began my journey of advocacy.”

While aging patients with cancer face unique challenges, it’s important to understand that treatment options are broad and the prognosis is good for most. “Nowadays, most cancers are either curable or manageable so that you can live several years with it,” says Extermann. “It’s not necessarily a death sentence.”

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As patients aged 65 or older receive a diagnosis of cancer, their treatment course and priorities may differ from their younger counterparts.

Treating Cancer as Patients Age

When Frank Giunta, 82, of Collegeville, Pennsylvania, was diagnosed with non-small cell lung cancer (NSCLC) in August 2020, he was assured by his caregivers at Penn Medicine’s Abramson Cancer Center in Philadelphia that he would not be alone during his treatment journey. Accompanying him would be a multidisciplinary supportive care team dedicated to ensuring that everything went smoothly, with as little impact as possible on his quality of life.

Giunta’s treatment was complex. He received more than 30 proton radiation treatments and multiple sessions of chemotherapy. A feeding tube was inserted when esophagitis from the radiation treatments made swallowing painful. He spent 17 days in the hospital, and three days after he returned home, his wife died from complications of lung and breast cancer.

“It was a difficult journey made more comfortable by supportive care,” Giunta says. A nurse visited twice a week and taught his two daughters how to care for him. A physical therapist assisted with balance issues, and a speech therapist helped him overcome swallowing difficulties related to the esophagitis.

“I wouldn’t have known what to do without supportive care,” Giunta says. “They made my life and recovery much easier.”

Giunta’s experience is typical among patients with lung cancer, who tend to skew older. According to the American Society of Clinical Oncology, the average age at the time of diagnosis for advanced lung cancer is 70. This age group also tends to have more comorbidities that can affect treatment type, outcomes and quality of life. The good news: A growing body of research suggests that the early introduction of supportive care greatly benefits older patients with lung cancer physically, emotionally and psychologically.

“Supportive care is essentially the many different measures we put in place to take care of the whole person,” says Dr. Christine Ciunci, an assistant professor of clinical medicine and section chief of hematology-oncology at Penn Presbyterian Medical Center. “We provide treatments, either curative or palliative, to help patients live the best life that they can and feel their best for the longest amount of time possible. It’s a multidisciplinary approach that includes cancer treatments as well as the prevention and treatment of side effects, social work, nutrition, physical therapy, speech therapy, home care, palliative care and management of comorbidities such as COPD, heart disease and diabetes. Supportive care encompasses all of these things and is what I spend a lot of focus on as a thoracic medical oncologist.”

Supportive care for older patients with lung cancer has evolved in recent years as researchers explore its need, scope and efficacy. Key aspects are a greater appreciation of the complexity of cancer care and the increased role of supportive care throughout the process, says Dr. Arif Kamal, an associate professor of medicine at Duke University School of Medicine and a member of the Duke Cancer Institute in Durham, North Carolina. “Referral to a specialist, such as an endocrinologist for diabetes, makes sense because it’s good care to provide that extra layer of support to the patient,” he explains. “Cancer care delivery in 2021 is a team sport, and as a team sport, we can’t be shy about asking for help when we need it.”

Equally important is acknowledgement that supportive care is most effective when started early in the treatment process. Helping to drive this concept are the findings of a seminal 2010 study published in the New England Journal of Medicine, which found that among patients with metastatic NSCLC, early palliative care led to big improvements in quality of life and mood. In addition, compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.

“Over the years, palliative care has evolved and become a standard of care for these patients,” Ciunci says “We have more options to help patients and more supportive measures in place than we did even just a few years ago. It has been very beneficial for our patients.”

Supportive care goes by a number of different names, Kamal notes. The majority of programs call themselves palliative care, some call themselves supportive and palliative care, and others call themselves supportive care only. Among them, the services are essentially the same. “We advocate for multidisciplinary care that involves physicians, nurses, chaplains and social workers, at a minimum, but also care navigators, physical therapists and others,” Kamal says. “We find large variability across the country.”

Patients with lung cancer commonly require more supportive care than patients with other types of cancer due to their age, the stage of their disease and the presence of comorbid conditions, sometimes including intrinsic lung disease. “Patients with lung cancer can have significant symptom burden at the time of diagnosis, especially those with metastatic disease,” notes Dr. Robert Daly, a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center (MSK) in New York City. “They can have underlying pain from their metastases, as well as fatigue, loss of appetite, shortness of breath and cough, so there is a clear need within this patient population.”

Patients with lung cancer may also experience psycho- logical and emotional issues related to existential distress. Former smokers, for example, may feel depressed because they blame their lifestyle for their cancer. Others may experience conflict with their spirituality, questioning why they developed cancer despite living a healthy life, or believing that their cancer is some sort of punishment. Kamal recalls a patient who had received an abortion in her teens and refused pain management for her cancer because she felt she had to atone for her perceived sin.

“I don’t have the skills to deal with that, but I do have people on my team, such as chaplains, who do,” Kamal says. “It affects everything.”

Not all patients experience a crisis of faith, however. Patrick Hidalgo, 79, of Boynton Beach, Florida, turned to prayer to help him deal with post-operative pain and other issues following a diagnosis of stage 3A lung cancer in May 2020. “I don’t like taking drugs, and prayer was very effective for me,” Hidalgo says.

A patient’s need for supportive care is commonly deter- mined through a close assessment of their disease, symptoms, physical condition, home support, transportation options and much more. Through candid conversation, the supportive care team can help the patient determine their specific goals, whether curative or palliative, and create a plan to achieve those goals.

“The medical oncologist works closely with the patient to manage their symptoms, from the disease and from any toxicities resulting from treatment,” Daly explains. “But involvement of a supportive care specialist also helps benefit the patient by integrating their expertise with that of the medical oncologist.”

Supportive care is typically tailored to the patient, though certain aspects are common to all, Ciunci says. These include addressing the side effects of treatment and ensuring access to a social worker. “This is important to ensure the patient has all the resources they need at home,” Ciunci explains. “Home care is highly valued for these patients.”

Hidalgo received post-surgical wound care through a visiting nurse, who also taught Hidalgo’s wife, Josie, how to help him as needed. In addition, a physical therapist placed him on an exercise regimen to keep his body strong while he healed. The process was an eye-opener. “I was in great shape,” Hidalgo says. “I was riding a bike 10 miles a day. Then I got sick and everything changed.”

The early introduction of supportive care can have a positive effect on treatment outcomes and quality of life. “There are good studies that show that timing does matter,” says Kamal. “When we think about best-practice palliative and supportive care, we are talking within 12 weeks of diagnosis. The reason for that is, an ounce of prevention is worth a pound of cure when we talk about distress. If we start supportive care at the same time we start treatment, we can prevent complications from happening, anticipate them and have a plan in place to manage them. This keeps the patient from having to go to the emergency room at 2 a.m. when the pain worsens.”

Older patients with lung cancer sometimes encounter barriers to receiving supportive care. A lack of transportation is one of the most common, especially for those who may depend on family, friends or public transportation to get around. Many cancer centers have turned to telehealth to make visits with doctors and other care providers easier but, as Ciunci notes, a large percentage of older people do not have smartphones or laptops. “It can sometimes be difficult to connect patients to these valuable resources due to a lack of comfort with certain technologies,” she observes.

Financial difficulties also can be an obstacle to supportive care, Ciunci says. A patient who is seen by the oncology team once a week, for example, may be overburdened if required to return for a palliative care visit or physical therapy session on a separate day. Financial issues may include the expense of child care, lost work time, and even the cost of gas and parking. Additionally, many patients cannot afford certain basics integral to their care, such as nutritional supplements and home health equipment.

“We may be able to provide access to samples, coupons and programs, but it doesn’t take care of everything,” Ciunci says. “Some patients may be reluctant to come in for visits because they simply can’t afford the copay. Luckily, at Penn Medicine, we are able to offer financial assistance and specialized resources, but not every program can.”

Over the past year, patients with lung cancer faced another unexpected obstacle: the COVID-19 pandemic. When it came time for him to begin chemotherapy, Hidalgo decided to have it done at MSK, where COVID-19 cases were dropping, rather than in Florida, where cases were spiking. The supportive care he received from his oncology team at MSK was primarily process oriented, he says, as they guided him through the realities of treatment, side effects and more.

Supportive care is an essential key to the effective treatment of lung cancer, and older patients are encouraged to become their own advocates. “My advice is for patients to ask their oncology team early and often about supportive and palliative care resources, to add all the extra layers of support they can to their team, so that several minds are thinking about their distress from all angles,” Kamal says. “I would ask (as a patient), ‘What supportive or palliative care resources do you think could help me?’ and predicate the question on a clear and mutual understanding of what quality-of-life issues the patient and their family are facing. If everyone isn’t on the same page, there is a real risk of the oncologist underappreciating the unmet needs that can be addressed through additional services.”

Find a team that you work well with, Ciunci adds. “Your oncologist should be asking, ‘What are your goals for your cancer treatment, and what do you want for the future?’ I think that’s extremely important so that your team can tailor your treatment approach based on your objectives,” she notes. “And of course, if you haven’t been given access to a social worker, nutritionist, physical therapist or palliative care provider, you should ask. These are things that should be readily available to you during treatment.”

From a patient perspective, Hidalgo encourages others to reach out to support organizations such as the GO2 Foundation for Lung Cancer. Hidalgo benefited greatly from a phone buddy there and now works in a similar capacity helping others. “My interaction with the GO2 Foundation was the most impactful component of my recovery,” he says. “Now I help out by reaching out to others in the lung cancer community.”

Because of their age, disease state and comorbid conditions, older patients need supportive care.

Early Introduction to Supportive Care Greatly Benefits Older Patients With Lung Cancer

A diagnosis of cancer can be emotionally devastating, but the personal trauma seldom ends there. The overall cost of treatment can be equally catastrophic to a patient’s bank account, especially if that person lacks adequate health insurance, analysts report. It’s not surprising, then, that care-related money issues are frequently cited as the primary cause of personal bankruptcy among families ravaged by cancer.

However, these families don’t have to struggle alone, thanks to organizations that provide free or discounted services and goods to patients battling the disease and struggling to make ends meet.

Total spending for cancer care in the United States was estimated at around $125 billion in 2010 and is projected to increase between 27 and 39 percent by 2020, reported Milliman, an independent actuarial and consulting firm, in a 2017 analysis of care costs specific to breast, lung and colorectal cancers.

When cancer strikes, the financial impact can be immediate. The study, commissioned by Pfizer, tracked the total cost of diagnosis and treatment over a five-year period, including the patient’s out-of-pocket portion, for roughly 35,000 commercially insured people with lung, breast or colorectal cancer. The results revealed that the average health care spending per patient increased from less than $2,000 in the month preceding diagnosis to as high as $25,000 in the month of diagnosis. The patient’s out-of-pocket responsibility similarly spiked dramatically, averaging $1,800 to $2,900 in the month of diagnosis alone.

The cumulative costs can be staggering. According to the Milliman report, total health care spending four years after diagnosis averaged $101,000 for breast cancer, $165,000 for colorectal cancer and $281,000 for lung cancer. The patient’s average out-of-pocket responsibility for that same time period totaled $7,531 for breast cancer, $8,442 for colorectal cancer and $11,180 for lung cancer. That does not include other major costs, such as insurance premiums and expenses associated with transportation, time off work and child care.

“Most of the time these costs are not covered by insurance, so it can be a downward spiral for many,” says Steven Hansen, managing director of Cancer Horizons, an organization that has one of the largest online directories of free products and services for patients with cancer nationwide. “I hear stories every day. People are trying to get better, but they’re also trying to deal with these fundamental lifestyle, cost-of-living-type issues.”

The patients tracked for the report had the benefit of employer-sponsored insurance, which negotiates a lower rate for the medical care provided, and then pays the lion’s share of treatment expenses. Even so, the added expenses associated with diagnosis and ongoing treatment, along with related costs for travel and lost wages, can be financially overwhelming. For those who lack insurance, are self-insured or need access to hospitals or treatments not covered by their insurance, the costs can be dramatically higher. Facing financial hardship can be demoralizing, but help is available, ranging from transportation to and from treatment to legal assistance to scarves and wigs for those who lose their hair due to chemotherapy.

Most assistance organizations require applicants to fill out online request forms. The amount of personal information asked for ranges broadly, but almost all require some proof that the applicant has cancer and is genuinely in need. Sometimes this may come via a Facebook page, but others require a letter from a physician.

People should not be deterred by the paperwork and take advantage of the goods and services available to patients and their caregivers, says Nancy Novack, founder and executive director of Nancy’s List, a nonprofit organization dedicated to assisting patients in need. “Such programs go a long way toward eliminating stress,” she says. “Participation increases the number of people who are on your side and gives you hope.”

Novack and Hansen both established their charitable organizations following a personal experience with cancer. For Novack, it was a successful fight against stage 4 ovarian cancer; for Hansen, it was months of caring for his father after a diagnosis of colon cancer. Both say after realizing the challenges faced by patients with cancer, they decided to fill an obvious need. “This is an extremely underserved market,” Hansen says. “Our sole mission is to provide com-passionate resources for patients with cancer. Everything is driven by the patients.”

Aside from the emotional and financial toll, cancer brings physical side effects, too — hair loss during chemotherapy; brittle nails; rough, flaky or discolored skin; sores and scars. Look Good Feel Better offers complimentary group, individual and online sessions that include lessons on skin care and cosmetics, nail care, wigs and turbans, accessories and styling to help men and women with cancer regain their self-esteem. To learn more, call the 24-hour hotline at 800-395-5665 or visit lookgoodfeelbetter.org. For men’s services, visit lookgoodfeelbetter.org/programs/men.

Having cancer doesn’t have to mean the end of having fun. Several organizations provide free experiences such as camping retreats and outdoor challenges that bring those battling cancer together with people who have gone through it.

Camp Good Days and Special Times provides free camp services for children who have cancer, have a parent or sibling with cancer, or lost a parent or sibling to cancer. Weekend adult retreats are also offered. To learn more, visit campgooddays.org.

Camp Mak-A-Dream is free to cancer survivors between ages 18 and 40. Campers can participate in activities like swimming, horseback riding, field sports, pottery, weaving and jewelry making. The camp also offers adult retreats. To learn more, call 406-549-5987 or visit campdream.org.

First Descents provides outdoor adventures of up to week, at no charge, for young adults aged 18 to 39 years affected by cancer. To learn more, call 303-945-2490, email info@firstdescents.org or visit firstdescents.org.

Project Koru brings the healing power of community and the outdoors for cancer survivors, who can participate in surfing, stand-up paddling, outrigger canoeing and snowboarding. To learn more, call 415-617-5678, email info@projectkoru.org or visit projectkoru.org.

The Hole in the Wall Gang Camp, founded by actor Paul Newman in 1988, was created to help seriously ill children celebrate fun and friendship for free. To learn more, visit holeinthewallgang.org.

Keeping family and friends updated on health can be overwhelming for patients. However, these resources try to make this job easier by keeping communication in one place.

CaringBridge lets patients post mass updates to everyone they choose to include in a private space; the organization provides emotional support, too. To learn more, call 651-789-2300 or visit caringbridge.org.

Lotsa Helping Hands simplifies the process of organizing help. Family and friends sign up to make meals, give rides to medical appointments, or stop by to say hello. To learn more, email info+contactus@lotsahelpinghands.com or visit lotsahelpinghands.com.

For many patients with cancer, as well as survivors, exercise such as yoga can benefit both body and mind. Certain fitness programs help alleviate physical side effects such as lymphedema, while others reduce stress and anxiety.

Cancer Support Community offers free fitness programs, cooking classes and nutrition lectures. To learn more, call 888-793-9355 or visit cancersupportcommunity.org/locations.

Livestrong at the YMCA offers free programs around the country. To learn more, call 855-220-7777 or visit livestrong.org/what-we-do/program/livestrong-at-the-ymca.

Yoga Bear provides a list of yoga studios around the country that offer free or reduced-cost classes to patients undergoing treatment. To learn more, visit yogabear.org.

The following organizations offer free headwear such as hats, scarves and wigs to patients who experience hair loss, a common side effect of chemotherapy.

• The Breast Friends Hat Project: Call 888-386-8048 or visit breastfriends.org. • EBeauty Community: Email alex@ebeauty.com or visit ebeauty.com. • Friends Are By Your Side: Call 856-582-6600, email wigs@fabys.org or visit friendsarebyyourside.com. • Good Wishes: Call 888-778-5998, email info@ goodwishesscarves.org or visit goodwishesscarves.org. • Heavenly Hats Foundation: Call 920-362-2668 or visit heavenlyhats.org. • Lolly’s Locks, call 240-428-1984: Email info@lollyslocks.org or visit lollyslocks.org.

Some local affiliates of Susan G. Komen distribute free wigs. Call your local chapter to see if they offer wigs in your area.

Patients undergoing active treatment likely will not have the strength or feel up to doing household chores and cleaning. That’s where Cleaning For A Reason comes in. Created in 2006, the nonprofit organization works with maid services throughout the United States and Canada to offer free housecleaning. To learn more, call 877-337-3348, email info@cleaningforareason.org or visit cleaningforareason.org.

Patients with cancer often find themselves at odds with insurers or face other disputes over access to coverage or benefits. This process of appeal can be daunting and stressful, but Cancer Legal Resource Center offers free information that may help. To learn more, call 866-843-2572, email CLRC@drlcenter.org or visit cancerlegalresources.org.

Treatment for cancer is stressful enough, but arranging and affording transportation to and from a hospital or cancer center can be trying, too. Sometimes treatment must be received at a care facility many miles away or in another state, a situation that can cause significant financial hard-ship. The following are some of the organizations that offer free ground or air transportation for patients.

The Air Care Alliance allows patients in need to reach out to all the charitable organizations offering free air transportation at once or specific member organizations. To learn more, call 888-260-9707, email mail@aircarealliance.org or visit aircar-ealliance.org.

The groups listed below can help, as well.

• AeroAngel: Call 303-817-7355, email mark@aeroangel.org or visit aeroangel.org. • Children’s Flight of Hope: Call 919-466-8593, email info@cfoh.org or visit childrensflightofhope.org. • Corporate Angel Network: Call 914-328-1313, email info@corpangelnetwork.org or visit corpangelnetwork.org. • The American Cancer Society’s Road to Recovery: Call 800-227-2345 or visit cancer.org/treatment/support-programs-and-services/road-to-recovery.html. 

Organizations offer free services and goods for patients with cancer. 

Help Doesn't Cost a Thing

“After a cancer diagnosis, you can go into a shell and look for what is comforting and familiar. That was food for me. I wish I had the forethought to have released my anxiety with a walk instead of overeating.” — SUSAN YANKEE - PHOTO BY ANGELA CHICOSKI

Susan Yankee, an opera singer and voice teacher in Madison, Connecticut, was diagnosed with breast cancer in February 2015 at age 48. She had a single mastectomy and reconstruction, but didn’t need chemotherapy, and today takes the hormonal drug tamoxifen daily.

Yankee admits to being overweight at the time of her diagnosis. She knew she needed to lose weight, but felt overwhelmed by her cancer and started to “stress eat” to help her cope emotionally. As a result, she gained 10 pounds over the next six months. “After a cancer diagnosis, you can go into a shell and look for what is comforting and familiar,” Yankee says. “That was food for me. I wish I had the forethought to have released my anxiety with a walk instead of overeating.”

Yankee is far from alone, oncologists report. In fact, as the obesity epidemic in the United States worsens, cancer specialists are seeing more and more patients who are either overweight or obese at the time of diagnosis. This is concerning, they say, because obesity can adversely affect treatment outcomes, influence mortality and increase a patient’s risk of recurrence.

The good news, experts say, is that it’s never too late or impossible to lose weight and, even after a cancer diagnosis, trimming down may bring many lasting health benefits. Studies show that simple, common-sense plans for healthy eating and exercise — particularly those that are supervised through programs aimed at survivors of cancer &mdash; are associated with lower cancer risks, and for those with cancer, a smaller risk of recurrence. Whether these interventions are truly responsible for this decreased risk is not proven, but experts assume it to be the case. There are several controlled trials in progress that are formally testing whether exercise or diet aimed at both conditioning and weight loss could have a favorable impact on cancer risk.

Obesity is measured using body mass index (BMI), which is calculated by dividing a person’s weight in kilograms by their height in meters squared. A BMI of 25 to 29.9 is considered overweight; 30 or higher is considered obese. According to a report in the 

Journal of the American Medical Association

, in the years 2013-2014, 35 percent of American men and more than 40 percent of women met the clinical definition for obesity. Rates of obesity are also rising among American children, of whom around 17 percent are considered obese, reports the National Cancer Institute (NCI), quoting a 2007-08 National Health and Nutrition Examination Survey.

Excess weight can contribute to a variety of health issues, including heart disease, hypertension and diabetes. It can also increase one’s chances of developing certain types of cancers, including breast, endometrial, kidney, gallbladder, esophagus, pancreas, thyroid and colon, multiple studies show. In fact, the results of a 2003 study published in 

estimated that the proportion of all deaths from cancer attributable to overweight and obesity in U.S. adults ages 50 or older may have been as high as 14 percent in men and 20 percent in women. Observed the authors, “Under the assumption that these relations are causal, the public health implications for the United States are profound: More than 90,000 deaths per year from cancer might be avoided if everyone in the adult population could maintain a body-mass index under 25.0 throughout life.”

The exact mechanism behind this phenomenon is not entirely understood, but researchers believe a number of factors may play a role. One of the strongest contenders is inflammation, notes Jennifer Griggs, M.D., professor of medical oncology and of health management and policy at the University of Michigan in Ann Arbor. “Obesity is considered a chronic inflammatory state,” Griggs explains, “and an inflammatory state may be pro-carcinogenic.”

Certain hormones are another suspected mechanism. The aromatase in fat tissue converts androgens to estrogen, and this elevated estrogen level has been associated with a higher risk for breast, endometrial and other forms of cancer, reports the NCI. Fat cells also produce hormones called adipokines that may stimulate tumor growth, and are suspected of directly or indirectly affecting other tumor-growth regulators.

Insulin and insulin-like growth factor-1 are also under study. Commonly found in higher levels in the blood of obese people, these compounds are suspected of promoting the development of certain tumors, including kidney and colorectal cancer, reports the American Institute for Cancer Research.

The negative influence of obesity reaches further than increased cancer risk — excess weight can also affect treatment in a variety of ways, researchers report. One of the most important issues on this front is chemotherapy dosing. Until recently, oncologists commonly prescribed the same amounts of chemotherapy drugs to obese patients as they did to more slender patients, potentially underdosing their larger patients and negatively affecting treatment outcomes. “The concern was that the risk of toxicity associated with chemotherapy could be higher in obese patients because they were getting much larger doses than non-obese patients,” explains Joseph Sparano, M.D., associate director for clinical research at the Albert Einstein Cancer Center in New York.

The consequences of underdosing can be significant. A 2013 review by Gary H. Lyman and Alex Sparreboom, published in the journal Nature Reviews Clinical Oncology, found that a 20 percent reduction in chemotherapy dosing lowered remission and cure rates by half in animal tumor models. Another study, published in 2015 in the journal JAMA Oncology, found that a group of women with ovarian cancer, including some who were overweight and some who were not, had a 35 percent higher risk of mortality if they received less than 85 percent of the chemotherapy dose they should have gotten based on their weight, compared with women who received adequate dosing.

In 2012, the American Society of Clinical Oncology published revised clinical practice guidelines that encouraged oncologists to measure chemotherapy drugs based on a patient’s actual size and weight rather than ideal weight after studies showed that this practice did not cause extra side effects.

Obesity can affect outcomes in other ways, as well. For example, a 2013 study published in the 

 Institute suggests there could be a reactivation of dormant tumor cells across levels of fat, as evidenced by the fact that, in animals, where visceral fat is present, both circulating tumor cells and lung cancer metastasis are more likely to be seen. Additional evidence comes from the observation that receptors for growth factors that are elevated with obesity are commonly expressed on circulating tumor cells. The same study noted, too, that fat tissue can dramatically affect the metabolization of chemotherapy drugs, and thus influence efficacy and prognosis.

When cancers are linked to obesity, that doesn't always spell a negative impact on prognosis, however. A 2016 study published in the 

 found that, while obesity is a risk factor for clear cell renal cell carcinoma (RCC), a high BMI is a prognostic factor for improved survival in patients with metastatic RCC who have received targeted therapy. Several hypotheses have been proposed for this paradox, including the theory that longer survival among obese patients is due to a less aggressive disease subtype.

Obesity may also play a significant role in cancer recurrence, researchers suggest. It’s an issue of particular concern for certain breast cancer patients, because a higher BMI at the time of diagnosis has been associated with poorer outcomes in terms of recurrence and survival, says Heather Greenlee, N.D., Ph.D., assistant professor of epidemiology at the Columbia University Mailman School of Public Health in New York. “It appears that if women gain a substantial amount of weight following a breast cancer diagnosis, that also is associated with poorer outcomes,” Greenlee notes. A 2012 study published in the journal Cancer affirms this concept, noting that overweight and obese women diagnosed with early-stage, hormone receptor-positive breast cancer and treated with standard chemotherapy and hormonal drugs have a higher risk of recurrence and lower survival rates.

An issue of concern often unforeseen by patients with cancer is weight gain during treatment. Patients often assume that they will lose weight during their treatment regimens, and are greatly surprised when the opposite occurs. “We tend to think of cancer chemotherapy as causing weight loss, but when that happens, it’s usually from the cancer itself,” notes Griggs.

Weight gain during treatment is fairly common, especially among breast cancer patients, but researchers are unsure of the exact mechanism behind it. “One hypothesis is that women reduce their physical activity during treatment,” Greenlee says. “It also could be an effect of the drugs themselves. Likely, it’s a combination of the two.”

There is evidence that a woman can lose lean body mass during treatment, slowing her metabolism and, thus, her ability to burn calories; if treatment induces menopause, that may also cause weight gain.

“Cancer disrupts people’s lifestyles,” adds Sarah Kiser, M.S., R.D., a clinical oncology dietician with Cancer Treatment Centers of America at Western Regional Medical Center in Goodyear, Arizona. “There can be grieving and stress involved, along with life changes. Additionally, treatment can cause side effects that might result in choosing less-than-desirable foods, such as taste changes. If a patient is experiencing taste changes, they might crave comfort foods over a well-balanced diet.”

When weight gain does occur, it can be difficult to lose, adds Griggs. “It’s not their destiny to gain weight, but when patients think they’re losing weight and people want to help by bringing them meals and taking them out, they actually put on 10 pounds,” she observes. “That 10 pounds can be very hard to lose, whereas if they lose weight on chemotherapy, they are likely to gain that back.”

Yankee knows how difficult post-treatment weight loss can be. Upon enrolling in the Survivorship Clinic at Smilow Cancer Hospital at Yale New Haven, in Connecticut, she was placed in the LEAN Study, which looked at how weight affects survivorship. Initially, she was part of the control group, which meant she received only a brief meeting with a nutritionist and a pamphlet on healthy eating. Yankee continued to gain weight until she was provided with ongoing nutritional counseling and weight-loss tools, such a food journal, pedometer and weight-loss program book.

“Getting up to 10,000 steps a day was difficult, especially since the first week of the program I reopened stitches from my DIEP flap revision (the breast reconstruction) and needed to be careful about my exercise,” Yankee says. “But that same week, I lost three pounds from the food journaling and portioning alone. At the end I lost 25 pounds, and have lost five additional pounds since then.”

The program worked for many others in the study too, and its authors say their findings support the idea that weight loss interventions should be used to improve diet among breast cancer survivors.

Kiser, too, encourages all cancer patients to eat with nutrition in mind as they go through their cancer journeys. She recommends a diet rich in fruits, vegetables, whole grains, nuts and seeds, and light on red and processed meat such as bacon and sausage. She also suggests limiting saturated fatty acids, which come primarily from animal foods.

“I think every patient who faces a cancer diagnosis is interested in making dietary changes of some kind,” Kiser says. “It can be a positive point of change in someone’s life.”

Obesity can negatively affect cancer treatment outcomes, trigger disease recurrence and shorten longevity. Organized weight loss programs and exercise can help patients protect themselves.

Don Vaughan

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