Brain Tumors: A Practical Guide to Assessment

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Brain Tumors A Practical Guide to Assessment
Treatment
July 19. 2014 Oxnard September 27, 2014
Roseville 830 a.m. 1145 a.m. Presenter
Katie L. Buchanan, MS, CCC kbuchanan1_at_bak.rr.com

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Injuries and/or lesions are often described by
their location in the brain in combination with
simple Latin prefixes (e.g. sub, pre, intra)
www.healthcentral.com
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Basic functions of the brain
Often in brain injuries, more than one area of
the brain is affected. Damage can also be caused
by secondary complications such as swelling.
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Vasculature of the Brain
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The best, most poetic description of the lobes of
the brain compliments of a recent Mercedes Benz
commercial!!!
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Back to basicsCancer Cancer is a term used
for diseases in which abnormal cells divide
without control and are able to invade other
tissues. Cancer cells can spread to other parts
of the body through the blood and lymph systems.
(National CA Institute (NCI) at www.cancer.gov)

• The five subcategories of cancer are
• 1)       Carcinoma - cancer that begins in the
  skin or in tissues that line or cover internal
  organs.
• 2)       Sarcoma - cancer that begins in bone,
  cartilage, fat, muscle, blood vessels, or other
  connective or supportive tissue.
• 3)       Leukemia - cancer that starts in
  blood-forming tissue such as the bone marrow and
  causes large numbers of abnormal blood cells to
  be produced and enter the blood.
• 4)       Lymphoma and myeloma - cancers that
  begin in the cells of the immune system
• 5)       Central nervous system cancers - cancers
  that begin in the tissues of the brain and spinal
  cord. (NCI)
• All cancer cells can be placed into one of these
  subcategories.

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Stats and potential causes

• Potential causes of cancer
• 1) Chemical or toxic compound exposures
  Benzene, asbestos, nickel, cadmium, vinyl
  chloride, benzidine, tobacco or cigarette smoke
  (contains at least 66 known potential
  carcinogenic chemicals and toxins), and aflatoxin
  
• 2) Ionizing radiation Uranium, radon,
  ultraviolet rays from sunlight, radiation from
  alpha, beta, gamma, and X-ray-emitting sources
  (the primary concern in Japan at this time)
• 3) Pathogens Human papillomavirus (HPV), EBV or
  Epstein-Barr virus, hepatitis viruses B and C,
  Kaposi's sarcoma-associated herpes virus (KSHV),
  other bacteria are being researched as possible
  agents
• 4)       Genetics/family history (ACS.com)

• Statistics
• More than 200 types of cancers in existence
• There are more than 120 types of PRIMARY brain
  tumors (NCI, 2011)
• More than 80 of patients in clinical trials
  experienced speech, language and/or cognitive
  decline for up to a year post treatment
  (American Cancer Society at www.cancer.org, 2011)
• Up to 40 of patients with high grade gliomas are
  reaching a lifespan of up to 5 yrs post dx.
  (American Brain Tumor Association at
  www.abta.org, 2011)
• 40 of patients will be eligible for
  participation in a clinical trial at some point
  during their treatment (City of Hope at
  www.cityofhope.org)

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www.bibelex.org
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Tumor An abnormal lesion and/or group of cells
that serves no purpose. Types of
tumors1)       Primary Generally begin in the
CNS and do not metastasize2)       Secondary
Start in one area of the body and metastasize to
somewhere else. Most common cancers and where
they like to migrate
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Signs and Symptoms

• Chronic headaches
• Vision changes/loss
• Frequent dizziness
• Depression/mood and personality changes
• Hearing reduction/loss
• Hormonal changes
• Changes in sensation (numbness, tingling)
• Fatigue
• Hormonal changes
• Seizures
• Movement changes and/or loss
• Sensory changes and/or loss
• Associated with the location of the tumor, its
  size, and cerebral areas impacted.

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Diagnostics listed in order of occurrence during
the continuum of care
Step one CT scan. Pros 1) Can easily
diagnosis large structures in the brain. 2)
Cheaper than most other diagnostics 3) Faster
than most other tests (usually 30-60
minutes) Cons 1) Pictures are still life, 2)
Cant detect changes in vasculature. 3) Images
are B W, 4) Not sensitive to subtle changes in
the brain
Step Two MRI Pros 1) Can easily detect
abnormalities in blood flow,, 2) More efficient
at finding tricky margins/edges of tumors. Cons
1) Pictures are still-life, 2) More expensive
for hospitals and patients, 3) time consuming (90
min. ), 4) more restrictive (e.g. cannot use on
patients with some PO, pacemakers, shunts, vagal
nerve stimulators, etc.)
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Step Three Function MRI (fMRI) This image
displays the cortical surface in transparent
gray. Within the brain are shown fMRI activations
in teal, arteries in red, tumor in bright green,
and white matter fiber tracking in yellow
(MIT.edu)
Pros 1) Shows vacularity VERY clearly, 2)
shows not only anatomy, but also shows MOVEMENT
AND FUNCTION, 3) Can reveal feeder vessels and
where other cancerous material CAN spread. Cons
1) VERY expensive, 2) VERY long (1-2 hours), 3)
requires specialty equipment usually housed at
specialty hospitals, 4) Can be rebutted by
insurance companies (argue that a still-life MRI
may suffice), 5) Does NOT reveal what type of
cancer is present.
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PET Scan (Positron Emission Tomography) 1)
NPO x 6-8 hours prior 2) a tracer is injected
into the bloodstream or breathed in as a gas 3)
The patient waits about an hour for uptake of
the tracer 4) The imaging study is performed.
Sometimes patients are asked to read names or
letters if memory/language is being tested. Test
time requires between 1-2 hours. 5) Uses the
uptake of glocose to produce an image. 6)
Usually used well into the cancer
journey More active areas show up in warmer
colors (red/yellow/orange). If the brain is
burning glucose more quickly than normal,
high/abnormal activity is suspected.
fyeahmedlab.tumblr.com
Pros 1) Can identify hard-to-find tumor
margins 2) Can help determine if a tumor is
benign or malignant 3) Helps determine if
chemotherapy is/will be effective (by examining
the brains ability to absorb /uptake foreign
material) 4) Can help discern if multiple cancer
types are present Cons 1) Some patients have
reactions to the tracer itself, 2) results can be
skewed with patients who are diabetic, or on
corticosteroids and/or insulin.
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The WHO Tumor grading system

• GX Grade cannot be assessed (Undetermined
  grade)
• G1 Well-differentiated (Low grade)
• G2 Moderately differentiated (Intermediate
  grade)
• G3 Poorly differentiated (High grade)
• G4 Undifferentiated (High grade)
• Grading is based on irregularity of cells as
  compared to normal cells,
• vascularity, and likelihood of spreading.
• This scale is ONLY used for primary
  tumors.
• Secondary tumors and/or tumors from
  other types of cancers are graded using the
  Gleason scale ranging from 2-10 (NCI, 2011)
• Note Tumor grade should NOT be confused with
  the stage of a cancer. Cancer stage refers to the
  extent or severity of the cancer, based on
  factors such as the location of the primary
  tumor, tumor size, number of tumors, and lymph
  node involvement (NCI)

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Examples of what you may see in an imaging study
or oncology report

• Grade II frontal glioma mildly/moderately
  vascular (usually operable) tumor of the glial
  cells in the frontal lobe
• Grade IV frontopareitel glioblastoma highly
  vascular (often inoperable or able to be only
  partially resected), highly malignant , rapidly
  growing tumor of the glial cells.
• Grade III left parietal astrocytoma
  moderate/highly vascular malignant tumor
  involving the astrocytes in the glial cells

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The Underappreciated glial cell

• Types and Functions of Glia
• Astrocyte (Astroglia) Star-shaped cells that
  provide physical and nutritional support for
  neurons 1) clean up brain "debris" 2) transport
  nutrients to neurons 3) hold neurons in place
  4) digest parts of dead neurons 5) regulate
  content of extracellular space
• Microglia Like astrocytes, microglia digest
  parts of dead neurons.
• Oligodendroglia Provide the insulation (myelin)
  to neurons in the central nervous system.
• Satellite Cells Physical support to neurons in
  the peripheral nervous system.
• Schwann Cells Provide the insulation (myelin) to
  neurons in the peripheral nervous system.
• Note There are an estimated 10-50x more glial
  cells in the brain as compaired to the number of
  neurons. (Neuroscience for kids)

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• Abundant in the hippocampus and the cortex
• Most cells in the brain are either neurons or
  glia
• Neurons can adapt (neuroplasticity) glia
  historically thought to be unable (though new
  research is suggesting it CAN!)
• Glia regulate which messages are sent THROUGH the
  neurons, and WHEN
• Remarkable research in mice (Scientific American,
  2013)
• Q Why is this important?
• A Because the most common types of PRIMARY
  MALIGNENT tumors originate in these cells! They
  are called gliomas.

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This picture illustrates the the relationship
between astrocytes and blood vessels. The dark
'star-like' figures are the astrocytes.
Astrocytes provide nourishment to neurons by 1)
receiving glucose from capillaries 2) breaking
the glucose down into lactate (the chemical
produced during the first step of glucose
metabolism) 3) releasing the lactate into the
extra cellular fluid surrounding the neurons. 


http//blustein.tripod.com The uptake of
glucose is a critical function for brain cells,
which is why PET scans are so effective in
identifying types of cancers, effectiveness of
treatment and the often hard-to-see borders of
malignancy.
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• Whats in a name?
• Remember tumors are named using the following
  criteria
• Site of lesion
• Vascularity (blood vessels that are feeding it)
• Potential to infect healthy tissue
• Type of cancer cells the tumor contains AND
  whether or not there are more than one TYPE of
  cancer cells in the mass.

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Case in point

• You work in outpatient therapy. Your team
  receives a referral for an evaluation of a
  40-something woman who has recently been
  diagnosed with a L temporal meningioma (labeled
  as grade II). She has mild word finding
  difficulties and complains of STM loss. She
  started radiation three weeks ago. You see her
  for 6/8 visits, but she is unable to complete
  her outpatient therapy due to fatigue (she cant
  handle tx while doing radiation).
• 2) Eight months later, the same woman appears
  on your inpatient rehab floor s/p craniotomy due
  to a L frontotemporal astrocytoma (stage
  unspecified). Her neurosurgeon writes in his
  report it is a gross/total resection of the
  tumor. She presents with markedly increased word
  finding problems, visual spatial deficits and R
  hemi. She is now very disinhibited, aphasic and
  cusses a lot. She stays on rehab for 3 weeks,
  then is discharged to a local day treatment
  program.
• 3) Another year passes, and the same woman
  is admitted a second time to your rehab unit, now
  s/p a bifrontal craniotomy s/p diagnosis of a
  glioblastoma multiforme. Her aphasia is worse,
  initiation is now very poor, and she has
  significant problems with the oral phase of
  swallowing (she just chews and chews and
  chews.). She is also a new diabetic.

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Huh? What the heck happened?!

• Doctors tried to treat the tumor. It
  probably didnt work as well as they had hoped or
  the patient couldnt tolerate treatment.
• She did NOT grow another tumor (though this can
• happen in rare cases)
• Rather, as it grew, the tumor changed
  characteristics/morphed into something
  different. It also infiltrated another area of
  the brain.
• RememberThose characteristics that change are
  vascularity, infiltration of healthy tissues, and
  complexity and/or number of different types of
  cancer cells.
• Therefore The NAME of the mass changes as the
  characteristics change.
• ).

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• Other Helpful Hints
• Low grade astocytomas often change into high
  grade gliomas as they grow.
• The craniotomy site(s) and incision markers are a
  reflection of where the mass traveled.
• In late stage gliomas (especially glioblastoma
  multiformes), cancer cells often cross
  hemispheres. This makes them VERY difficult to
  treat.
• Glioblastomas are ALWAYS STAGE IV.
• Stage IV astrocytomas are essentially the same
  thing as a gliobastoma.
• Grade IV tumors also have margins that are VERY
  hard to find. Many of them even grow tendrils or
  appendages (think octopus).
• Despite the prognosis of stage IV tumors,
• many people are living upwards of a year after
  their
• diagnosis due clinical trials and new
  developments
• in cancer research. However, they are eventually
• terminal.

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Treatment options What
they are and how the impact treatment
Understanding the cell cycle

• Chemotherapy
• Radiation
• Radiosurgery
• Traditional surgery
• Bone marrow transplants
• Gene therapy
• Hormone therapy
• Holistic approaches
• Palliative Care

At each stage of mitosis, there is a built-in
check point. If cellular structure is
incomplete or incorrect, mitosis cannot occur.
Scientists rely heavily on these checking
points as opportunities to inhibit cancer cell
divisions with various types of medications.
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Craniotomy 101
Photos www.brain-surgery.us
Burr Holes initiating removal
The leathery dura mater Arachnoid
mater underneath of the
skull flap

• The patient is made NPO for appx 12/24 hours
  except meds
• The patient is wheeled to the O.R. and sedation
  is given
• Utensils and hardwear are counted pre-op
• Any necessary hair is shaven off
• The patients head is clamped into a tripod (of
  sorts). Pins secure the head into the vice
  (these small wounds will heal in 1-2 days).
• A line is drawn on the skin to demarcate the
  incision n the scalp
• The scalp is cut open and peeled back as far as
  need be
• The skull is marked to demarcate the size/shape
  of the bone flap
• Burr holes are made with small drills to begin
  skull flap removal
• A bone cutting blade cuts the remainder of the
  skull flap
• Necessary tissue is excised.
• The skull flap can either be left off or replaced
  dependent upon the amt of swelling incurred.
• Utensils/hardwear are counted and recounted

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Common craniotomy terms

• Cranitomy Term used for cutting open the brain
  to alter structure or function. Does not usually
  involve removing brain tissue.
• Craniectomy Term used for opening the brain and
  removing what was normal brain tissue. (Tumors
  are NOT considered part of the normal brain.
  Therefore, tumor removal is not considered a
  craniectomy).
• Partial resection Removal of part of the
• tumor (amount is usually unspecified in the
  chart
• but the patient /family usually knows!)
• Gross/Total Resection Removal of what the
  neurosurgeon believes is the whole tumor.
• While a total resection is great, be careful
• This may NOT mean the patient is cancer free.
• Chemo or radiation may need to follow.

Staples s/p this young ladys second crani.
www.photobucket.com
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Most common complications of undergoing a
crani

• Risk of infection of the brain itself
• Risk of infection of the skull flap
• Swelling (external or internal)
• Hydrocephalus (many patients require a shunt if
  this become uncontollable. These are known as
  Ventricular-Peritoneal Shunts or VP Shunts
•  Development of seizures
•  Development of diabetes insipidus (from
  corticosteroids used to reduced swelling)
•  Cerebral Hemorrhaging
• Stroke
• Weakness/paralysis/sensory loss due to focal
  damage
• Swallowing difficulties/aspiration pnuemonia
• Falls post-op

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Chemotherapy Medications that either cause
total cell death, or interrupt the cell cycle.
Apoptosis The suicide gene in cells that
cause normal cell death. This is the mechanism
that is often inhibited with cancer. Apoptosis
is inhibited and/or not allowed to occur.
The two types of chemo drugs

• Cytotoxic drugs
• Drugs that lead to cell death
•          Antimetabolites drugs that stop the
  body from making enzymes needed for tumor
  growth. Most common Mthotrexate (MTX). Risk
  They also inhibit normal enzyme production,
  possibly leading to protein deficiency and/or
  anemia.
•    Hormones Used to block proteins needed
  for tumor growth. Most common tamoxifen (used
  primarily in breast CA)
•          Anti-tumor antibiotics stops cell
  growth by changing the environment around the
  cell. Most common Rapomycin
•          Mitotic inhibitors plant based
  inhibitors of proteins that cancer cells need to
  breed. Most common Taxol
•          Alkylating agents drugs that bond to a
  malignant cells DNA to prevent reproduction,
  and/or prevent a damaged cell from fixing
  itself. Most common carboplatin, cysplatin,
  Temodar
•          Steroids Primary purposes is to
  reduce inflammation. Inconsistent research
  states they may have some impact on tumor
  cells.However, effectiveness is well documented
  in CNS lymphoma (ABTA,2010)
•  

• Cytostatic drugs
• (sometimes called targeted therapy
• Drugs that prevent tumor growth or mitosis
•          Angiogenesis the process by which a
  tumor grows a new blood supply to feed itself .
  Medications called anti-angiogenesis inhibitors
  prevent new blood vessels from growing around a
  tumor. Most common interferon, thalidomide.
  Often combined with another form of chemo to
  attack the tumor and its blood supply.
•          Drugs to prevent tumor resistance
  many tumors can become immune to medications as
  they change at the cellular level. These drugs
  keep the tumor susceptible to the impact of meds.
  Most common guanine derivatives
•          Growth factor inhibitors Meds that
  prevent critical proteins from feeding the tumor.
  Most common Gleevec (ABTA, 2010)
•  
•  

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Photograph by James L. Amos Gloved hands cradle a
bright hope in the war against cancer. A
researcher at a drug manufacturing plant in
Pennsylvania displays a petri dish of cisplatin,
a chemotherapy drug containing platinum. Cancer
cells divide and reproduce at highly abnormal
rates. Cisplatin attacks the cell cycle, killing
them and reducing the size of tumors.
Chemotherapy is one of the most successful
methods to combat cancer. (natgeo.com)
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Methods of Delivery
Traditional methods of delivery

• 1) Pill form
• 2) Intrarteriorly (usually via port in the chest
  or the upper arm)
• IV form
• Intrathecally (directly into the spinal cord
  given via a catheter attached to the port)
• Topically

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More recently developed delivery systems
Intracavitary Patented by Gliadel Once a
tumor is removed/debulked, Gliadel wafers are
implanted, and line the cavity in which the tumor
used to sit. (Gliadel.com)
Pros Highly effective and permanent until
saturated medication runs out and they dissolve.
Constant dose of medication in direct contact
with malignant tissue. Cons Wafers can
sometimes become infected, thereby not
suppressing tumor growth as anticipated, and
causing infections and/or abscesses. Requires a
subsequent craniotomy for removal if they become
infected. Dosage cannot be changed once they are
implanted.
1)      Convection enhanced therapy (CED) one
of the newest methods of delivering chemo. Uses
the natural physics of the body (gravity/constant
need to equalize pressure) to circulate/push
medications into brain tumor tissue more
naturally. More easily navigates through the
blood brain barrier by sneaking through with
other fluids. Requires a shunt/port (at least
one, sometimes more) to inject. Cool fact
Research is being done in attempts to include
tracers that will allow them to observe real
time movement of the drugs in and around a tumor.
These tracers would be mixed with the drug as it
is injected into the patients system (ABTA.com).

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The joys of treatment
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More joys of treatment
Note Some of your patients will have no side
effects at all. Others will have ALL of them.
Graph built from info extracted from NCI, ACS,
ABTA, and cookbooks listed in bibliography
section!
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Whatve labs got to do, got to do with it?All
summaries taken from MedlinePlus.org
                                     
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Chemo brain. Yes, its real.

• Definition Mild to moderate cognitive-linguistic
  changes that occur either during or after a
  chemotherapy regiment. Also known as chemo fog.
  
• Includes the following
• Short term memory loss 7) Fatigue (physical and
  mental)
• Difficulty concentrating 8) Short attention
  span
• Being unusually disorganized 9) Taking longer
  than normal to complete routine tasks
• Difficulty with word finding 10) Trouble with
  verbal memory (recalling a conversation)
• Difficulty learning new skills 11) Trouble with
  visual memory (Mayo Clinic, 2009)
• Difficulty multitasking
• Interesting fact One of very few medical terms
  that originated and was adopted from
• the outside in. Now recognized in all medical
  dictionaries and med schools as a
• legitimate side effect of treatment. Recognized
  initially without any scientific data
• and/or definitive diagnostic studies (Mayo,
  2009).
• Nomenclature was coined by breast cancer support
  groups (actual date unknown, but emerged sometime
  post the year 2000).

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The study survivors were waiting for

• Title Self-reported cognitive impairment in
  patients with cancer.
• Funded by The American Society of Clinical
  Oncology
• Published in Journal of Oncology Practice, 2007
• Sample 595 patients in multiple centers
  undergoing treatment for solid tumors (locations
  unspecified).
• Treatments included radiation, chemotherapy, or
  both.
• Method Patients given a rating scale between
  0-10. Rated themselves on a) concentration and
  b) memory
• 0 not present / 10 as
  bad as you can imagine
• A score of 7 or more deemed as
  severe
• Key terms
• Baseline before treatment began (T1)
• Pt report of being at their worst during
  treatment (T2)
• 6 months after treatment ended (T3)
• Meaningful Outcomes (The take home message!)
• Cognitive deficits were less severe in those
  patients receiving ONLY radiation

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Radiation therapy How it works

• 5 purposes of radiation
• To shrink a tumor
• To eradicate a tumor
• For palliative reasons
• For prophylaxis
• Preferred in pediatrics

Many patients are on medications called
radioenhancers. These drugs make tumors
more susceptible to the impact of radiation.
Radiation is measured in rads (radiation
absorbed dose). Average dose appx 200
rads/cycle (computing case.org) RADIATION IS
CUMULATIVE

• Types of radiation therapy
• Conventional radiation Delivers full dose
  radiation to the tumor itself and the margins
  round it. Most common type of therapy given for
  primary brain tumors. Problem it is NOT
  selective in what it hits. Normal brain tissue is
  inevitably affected. Often given in slow daily
  doses. Radiation is CUMULATIVE and desired dose
  can take several weeks to reach. Beams also
  disperse easily when they hit the skin (ABTA,
  2010).
• Radiosurgery Frequently used for secondary
  tumors that have metastasized to the brain.
  Generally used on masses that are easily seen,
  and where the likelihood of unseen tumor cells is
  low. (ABTA, 2011).
• Prior to radiosurgery Patients will undergo
  radiation mapping, be fitted for a facemask (if
  the tumor is in the brain) and undergo 1-2 dry
  runs prior to actual radiation delivery. Often
  put on steroids, anticonvulsants or both.

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• Units of Measurement
• Radiation doses for cancer treatment are measured
  in a unit called a gray (Gy).
• A Gray the amount of radiation energy absorbed
  by 1 kilogram of human tissue. (NCI.com)
• Most cumulative doses are between 20-60 Gys.
• 
  
• Fractionation
• The term used for giving small doses at a time.
• For adults, patients range between between 1.8
  2 Gy fractions per dose. A common schedule is
  this dosage given 5 days a week for x number of
  weeks.
• A common dose for children is between 1.5-1.8 Gy
  per dose..
• Sometimes two fractions/day are given toward the
  end of a treatment regiment. This is known as a
  boost since small tumors at the end of
  treatment can repopulate more quickly.

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What terms are used for radiation
measurements? Radiation is measured in different
ways. Measurements used in the United States
include the following (the internationally used
equivalent unit of measurement follows in
parenthesis) Rad (radiation absorbed dose)
measures the amount of energy actually absorbed
by a material, such as human tissue (Gray100
rads). Roentgen is a measure of exposure it
describes the amount of radiation energy, in the
form of gamma or x-rays, in the air. (Roentgen
equivalent man) measures the biological damage of
radiation. It takes into account both the amount,
or dose, of radiation and the biological effect
of the type of radiation in question. A millirem
is one one-thousandth of a rem (Sievert100
rems). (www.epa.gov)
Radiation Source Dose (millirems)
Chest x-ray 10
Mammogram 30
Cosmic rays 31 (annually)
Human body 39 (annually)
Household radon 200 annually
Cross-country airplane flight 5
Legal limits 5 remsyear (for 18 yr old men),
500 millirem for pregnant
women
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Diagram compliments of the United States Nuclear
Regulatory Commission _at_ www.nrc.gov
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Tobacco and radiation

• It's not from just from burning tobacco, -- it's
  from inhaling radiation absorbed by the tobacco
  plant while it grows in the field.
• Radioactive materials in the atmosphere adhere to
  sticky tobacco leaves. The materials remain on
  the plant throughout the manufacturing process.
  The use of Apatite--a phosphate
  fertilizer--increases the radiation absorbed by
  the tobacco plant.
• The lead-210 and polonium-210 radiation emitted
  by the tobacco smoke is trapped in the lungs of
  the people exposed to it.
• Tar from the smoke also builds up in the lungs
  and enables them to trap the radiation more
  efficiently. Over the course of decades of
  inhaling tobacco smoke, the smoker's lungs are
  damaged, and the smoker and folks exposed to the
  second-hand smoke -- may develop lung cancer
  source EPA/www.discovery.org)

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Radiation mapping
www.natgeo.com
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Three types of radiosurgery
Pre surgery Mapping building a specific
facemask for delivery of beams into the correct
are of the brain.
Type 2 linear accelerator (lineac). Can be
used for both conventional radiation delivery or
radiosurgery. Beams can be computerized to meet
the exact shape of a tumor
Type 1 Cobalt 60 systems radiation beams. Most
common type Gamma Knife 201 beams focused
into one area of the brain
Type 3 Cyclotrons. Nuclear reactors capable of
smashing atoms to release harnessed proton,
neutron and helium ion beams
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Figure 4.
Home / On the Cutting Edge of Care On the
Cutting Edge of Care by Susan WesslingMinority
Nurse Writer When Evelyn Badran, CNRN,
graduated from high school in 1980, she had no
idea that a career in nursing was in her future.
Today, nearly three decades later, she is not
only an experienced and successful nurse but is
literally working on the cutting edge of cancer
care. As coordinator of the Gamma Knife suite at
the Neurologic Orthopedic Hospital of Chicago
(NOHC), Badran helps treat brain tumor patients
with a highly advanced technology that was
virtually unheard of 15 years ago. Gamma Knife
radiosurgery is a high-precision radiation
delivery system that is used to treat abnormal
brain tissue in a single session without surgical
incisions. A helmet- like frame is attached to
the patients head using pins and local
anesthetic, allowing targeted radiation to
destroy the cancer cells while minimizing the
effects on healthy surrounding tissue. Because
the procedure is non-invasive and virtually
painless, it causes little discomfort or
post-operative recovery pain and patients can
return to their usual routines almost
immediately. I know I am helping to make a
difference in patients lives with the help of
this amazing equipment, Badran says. While she
now spends her days providing state-of-the-art
nursing care, her ambitions as a teenager were
quite different. Growing up in La Paz, Bolivia,
Badran originally wanted to become an
architect. She attended a Catholic high school
that required all students to provide community
service to a population in need. I chose to
volunteer in an orphanage, she recalls. After
my service requirement was completed, I
couldnt separate myself from the children at
the orphanage. I just needed to be there and be
helping. Somehow it captured my heart. In that
sense, I knew I had a passion to help people, but
nursing was never in my mind. Two years after
graduating from high school, Badran immigrated to
the United States with her brother. Leaving her
parents behind, she settled in Chicago, where her
aunts, uncles and cousins were living. Like many
immigrants, she immediately felt the impact of
the language barrier. My English was very
basic, she says. When my brother and I moved
here, our uncle told us, You are not going to
watch any television in Spanish. You need to get
used to the English language. So that is what
we did. An avid reader, Badran was upset when
she bought a book written in English and found
she could not read it. This made her determined
to work harder on becoming proficient in her new
language. I started paying more attention. I was
very strict with myself. I focused on what I
wanted, she explains. I had been here maybe
five months and I took ESL (English as a second
language) classes. By the eighth month, I was
reading that book. Still, Badran initially found
it difficult to adjust to American culture. Life
over here is very different compared to life in
my home country, she says. I lived in a main
city in Bolivia, but it was definitely a lot
smaller than Chicago. The way life is over here,
it demands more. It seems like you are working
all the time. You dont have time to do
everything you want to do. In South America, it
is a little more relaxed. Here families tend to
separate, live apart, she continues. In my home
country, families basically stay together.
Parents with adult children and their families
can all live in the same house. That was another
thing that was hard to adjust to when I came
here. Following Her Heart Despite her early
difficulties, Badran grew to love the culture in
America. She particularly appreciated the
opportunities for education. Enrolling in
college, she took the prerequisites for her
associates degree while trying to decide on a
major.     
A patient being fitted with a protective helmet
that is screwed onto his head prior to gamma
knife surgery. This helmet further directs the
beams of radiation to specific targets in the
brain (minoritynurse.com)
Concept of Gamma Knife stereotactic radiosurgery.
Multiple separate small beams of radiation
converge at the tumor target (aafp.org)
45
Side Effects of Radiation

• Impact during treatment
• Hair loss in the treatment area
• Mouth problems
• Nausea and vomiting
• Sexual changes
• Swelling
• Trouble swallowing
• Urinary and bladder changes
• Diarrhea
• Weight gain or weight loss (often due to
  simultaneous need for steroids)
• Note Late side effects may first occur 6 or
  more months after radiation therapy is over. They
  vary by the part of your body that was treated
  and the dose of radiation you received. Late side
  effects may include infertility, joint problems,
  lymphedema, mouth problems, and secondary cancer
  (NCI, 2011)

46
Radiation Recall

• What it is An inflammatory reaction that occurs
  in patients who have received chemo AFTER
  radiation (NIH.gov)
• The chemo essentially reactivates the EFFECTS
  of the radiation (not the radiation itself).
• May occur days, weeks, months or years after
  treatment
• Unknown cause/triggers

47
Radiation dermatitis seen in a case of head and
neck cancer treated with conventional external
beam radiotherapy. (Indian Journal of Burns _at_
ijburns.com)
76 y/o female s/p infiltrating L ductal breast
cancer s/p radiation. Received radiation appx 6
months prior to chemo. The addition of chemo
into her system triggered this condition
(F1000Research.com)
48
New Cutting edge options Novocure
(www.Novocure.com)

• A noninvasive technology in the clinical trials
  stage
• Referred to as TTF therapy TTF Tumor
  Treating Fields
• An Anti-mitotic treatment that slows or reverses
  tumor progression
• NOT an electrical stim unit!!! No electrical
  impulses are given
• Only side effect reported is minimal skin
  irritation at the transducer site..
• All cells are polarized. Novocure tampers with
  the polarity of the cells, causing them to
  actually REPEL each other instead of ATTRACT each
  other.
• Used in Glioblastoma in addition to chemo,
  radiation, surgery, etc.
• Also used in small cell lung cancers.

49
Photo compliments of Kris Circa, a glioblastoma
survivor previously seen at St. Jude Medical
Center (Fullerton) and now receiving her
Novocure treatment at UC Irvine. She also
receives Avistatin infusions every other week.
Per her, this is how the system works The
Novo is worn 24/7 plugged into a wall socket or
battery pack. It's quite a contraption. 4 arrays
are place in specific locations on my head and
the transducers emit opposing positive and
negative impulses to confuse cancer cells so they
don't develop. I know there is a better
scientific explanation, but I though the Cliff
Note version was better here. There's quite a bit
of info on-line about it.
50
Immunotheraputic VaccinesThese trigger the
bodys immune system to beef up the immune
system to fight cancern, or to restart a
suppressed system (ACS.org)

• Checkpoint blockade drugs
• Cancer cells are smart, and can sometimes fool
  the immune system into not attacking them.
• They essentially take advantage of the immune
  systems ability to discriminate healthy from
  non-healthy cells, and its failsafe to NOT
  attack normal cells.
• Checkpoint blockade drugs take the brakes off
  and tell the immune system to go after the cancer
  cells again.
• CTLA-4 and PD1

• Adoptive Cell Transfer Therapies
• Done by removing a patients own cells,
  re-engineering them and programming them to
  attack cancer and then reinserting them back into
  the patients body (ACS.org)
• Highly personalized treatment
• Very expensive and not easily duplicated
• Still in the clinical trials phase.

51
Hyperthermia The impact of heat

• Can cause changes at the cellular level and make
  cancer cells more sensitive to treatment
• If high enough, can kill cancer cells completely
  (ACS)

• High Heat
• (aka thermal ablation or local hyperthermia)
• Uses radio waves, microwaves or ultrasound waves
  to cook the tumor.
• HIFU High Intensity Focused Ultrasound
• Can be external or internal
• Usually used with recurrent tumors or patients
  who cant tolerate sx
• RFA (Radio Frequency Ablation) is most common
• Side effects bleeding, blood clots, pain,
  tissue damage, blistering

• Low Heat
• (aka regional hyperthermia
• Usually involves heating a cavity in the body
• Combined with radiation or chemo
• Difficult due to the need to sustain an exact
  temperature in a large area.
• Side effect include problems with the heart,
  blood vessels and major organs.
• Effective for cancers just below the skin.
• Perfusion Removing blood, heating it, then
  pumping it back in.
• Increasing core body temp to appx 102 using a
  special tent, thereby triggering the body to
  fight infection (www.Lemmo.com)

52
BSD Medical for Hyperthermia BSD Medical
Corporation develops, manufactures, markets and
services systems to treat cancer and benign
diseases using heat therapy delivered using
focused radiofrequency (RF) and microwave
energy.                                         
                                               
www.tecnosan.it
Many patients with cancer have lower than normal
core temperatures and cannot activate a fever.
As a result, they have great difficult activating
their immune systems. This system essentially
does it for them. Increases core temp to between
102 and 105 for appx 2 hours at a time. Can be
paired with chemo administration.
www.oncotherm.com
53
Other treatments in the works
                                                
                                                  
                                                  
                                       The idea
that geniuses exist has been around for a long
time, but the term has no definitive meaning or
use. Photo Credit thewritertype.blogspot.com

• Stem cell treatment (Peripheral blood, cord
  blood/tissue and bone marrow)
• Specialized lasers
• Photodynamic therapies drugs that are turned
  on by certain kinds of lights and have chemical
  reactions with oxygen in the blood.
• Blood / blood product donations or infusions
  (ACS)

The Genius Brain!
www.gettysburgian.com
54
Close up of surgeons' hands in an operating room
with a beam of light traveling along fiber optics
for photodynamic therapy. Its source is a laser
beam which is split at two different stages to
create the proper therapeutic wavelength. A
patient is given a photosensitive drug that is
absorbed by cancer cells. During the surgery, the
light beam is positioned at the tumor site, which
then activates the drug that kills the cancer
cells, thus photodynamic therapy (PDT).
www..wikepedia.org
55
Clinical trials show

• Food and Drug Administration (FDA) categories
  for describing the clinical trial of
• a drug based on the study's
  characteristics, such as the objective and number
  of participants.
• There are five phases Phase 0 Exploratory
  study involving very limited human exposure to
  the drug, with no therapeutic or diagnostic goals
  (for example, screening studies, microdose
  studies). Phase 1 Studies that are usually
  conducted with healthy volunteers and that
  emphasize safety. The goal is to find out what
  the drug's most frequent and serious adverse
  events are and, often, how the drug is
  metabolized and excreted. Phase 2 Studies that
  gather preliminary data on effectiveness (whether
  the drug works in people who have a certain
  disease or condition). For example, participants
  receiving the drug may be compared with similar
  participants receiving a different treatment,
  usually an inactive substance (called a placebo)
  or a different drug. Safety continues to be
  evaluated, and short-term adverse events are
  studied. Phase 3 Studies that gather more
  information about safety and effectiveness by
  studying different populations and different
  dosages and by using the drug in combination with
  other drugs. Phase 4 Studies occurring after
  FDA has approved a drug for marketing. These
  including postmarket requirement and commitment
  studies that are required of or agreed to by the
  sponsor. These studies gather additional
  information about a drug's safety, efficacy, or
  optimal use. (See also Study Phase data element
  on ClinicalTrials.gov.)

56
The financial side of things

• The pharmaceutical business is the second most
  lucrative business in the U.S. Oil is the first.
• Eleven of the twelve cancer drugs the Food and
  Drug Administration approved for fighting cancer
  in 2012 were priced at more than 100,000 per
  year, double the average annual household income,
  according to a report by the Journal of National
  Cancer Institute. (Kantarjian, abcnews.com)
• Most insurance companies have an 80/20 or 90/10
  payment set up. Out of pocket costs are
  generally 10,000/year PER MEDICATION considering
  the above costs.
• The out of pocket maximum for tax purposes is
  6,700/year BEFORE you can include medications as
  an itemized deduction.
• Many cancer patients have to either decrease
  their work load or go on long term disability.
  Once sick days and short term leaves have been
  exhausted, state disability will usually provide
  patients with appx. 60 of their gross income.
• Most clinical trials are NOT covered by major
  insurance companies as they are not yet proven to
  work. The sponsor of the clinical trial may
  provide some compensation, but it is usually a
  pittance compared to the financial overhead
  patients experience.

57
Common Costs incurred

• Immediate costs

• Subsequent costs

• Initial MD appts
• Diagnostics used for tumor detection (CT, MRI,
  labs, blood tests)
• Pre-surgical medications (corticosteriods,
  anticonvulsants)
• Surgery (if indicated)
• Post-op hospital stay
• Therapy (inpatient, then outpatient)
• Radiation mapping
• Radiation treatment
• Chemo medications
• Follow up visits
• Regular lab checks
• Consults with other professionals/supporting MDs
• Clinical trials Most insurance companies wont
  pay for experimental treatment. If they do, its
  only a small fraction.

• Lost wages
• Prosthetics and/or orthotics (commonly knows as P
  and O)
• Travel expenses (gas, food).
• Hotel accommodations
• Cosmetic needs (e.g. wigs, specialty make-up)
• Reconstructive surgery
• Escalating insurance deductibles
• Inability to obtain more insurance policies due
  to a now pre-existing condition
• Cost of caregivers and/or subsequent stays at
  other facilities along the continuum of care
• Legal fees for trusts, wills, etc.
• Funeral preparatory costs

58
Discipline-Specific skills sets helpful with
this population Beyond your textbook scopes of
practice!

• Physical Therapy

• Occupational therapy

• How to read specific MD orders re mobility (e.g.
  HR, BP, etc.)
• Knowledge of Prosthetics and orthotics, and how
  the cancer patient may tolerate these.
• Heightened awareness of seizures, triggers, etc.
• Special attention to safety many of these
  patients are anemic, bleeders and have very
  fragile skin.
• Wound care Patients undergoing chemo/radiation
  are often susceptible to open wounds and heal
  slowly.
• Energy conservation vs. muscle building

• Awareness of chemotherapy ports/central lines as
  they relate to dressing/bathing
• Clarifying MD orders for the above what to ask
  for and when.
• How to make skin contact (for bathing/dressing/to
  ileting) with patients who are on strong chemo
  (some patients cannot be touched w/o double
  gloving due to chemo chemicals transferring via
  skin to skin contact or via bodily fluids)
• Proper disposal of bodily waste
• Adaptive techniques for medication delivery (e.g.
  adaptive techniques for injections if a pt is a
  new diabetic with a new hemi, etc.)
• Implications for child care, driving (reporting
  to DMV).

59
Discipline skills sets (cont)

• Speech therapy

• Knowledge of how chemo/radiation effect the mouth
  (skin/mucous membranes)
• How treatment impacts smell and taste
• Knowledge of how medications impact the
  swallowing mechanism
• Accommodating dietary restrictions into a
  dysphagia diet
• Knowledge of foods/liquids/textures/
• temps to help with oral pain management
• Impact of chemo/radiation on dentition
• Handling weight loss
• Malnutrition/dehydration
• Strategies for intake of medications
• Knowledge of comfort measure protocols and
  waivers for dysphagia diets is patients who are
  most likely going to die.
• Knowledge of NG, PEGs, TPN
• Implications for E-stim, MBS studies, etc.
• The basics of how to read a CXR

• Recreational Therapy

• Peer support networks
• Organizations for helping patients resume leisure
  activities on a modified basis
• Social networking on the floor
• Nontraditional therapy options (w/ MD clearance)
  e.g. Thai Chi, music tx, pet therapy
• Helping with computer programs to offer peer
  support/resources
• Special celebrations (e.g. Christmas parties,
  potlucks, etc.)
• Knowledge of community organizations for patients
  with special needs

60
Discipline skills sets (cont)

• Nursing

• Social Work

• Special attention to skin care/prevention of
  wounds
• Knowledge of most common infections
• Special considerations with lines, indwelling
  ports and how to maintain them
• Proper methods of disposing , sharps, meds and
  chemotherapy agents
• Proper methods of disposing bodily waste
  (biohardardous)
• When/how to call consults those enlisting comfort
  measures (e.g. palliative care, spiritual care,
  etc.)
• Oral hygiene/hydration/nutrition needs
• Difficulties in swallowing
• Recognizing subtle changes in medical status
• Acute awareness of labs and what they mean
• Manners, kindness and compassion
• A sense of humor
• Thick skin and an iron stomach

• Handles most insurance issues
• Catastrophic Case Manager - case managers
  with specialty training to assist those patients
  in which
• Length of stays may be long
• Exorbitant funds /costs are required
• Insurance companies are proving difficult
• Orchestrate follow up appts
• Orchestrate initial round of meds (in conjunction
  w/ nursing)
• Knowledge of support groups
• Methods of financial support (e.g. scholarships,
  philanthropic organizations

61
Everybody should know the basics of

• Skin care
• Swallowing/dysphagia precautions
• Effects of medications (and NOT just chemo meds!)
• Heart rate/BP
• Seizure precautions/what to do if one occurs
• Mobility restrictions/precautions
• How to operate restraints
• Simple strategies to ease pain
• How to listen to your patient!
• When to push and when to call it a day.

62
Palliative care an unsung resource

• Improving the quality of life of patients and
  families
• Palliative care improves the quality of life of
  patients and families who face life-threatening
  illness, by providing pain and symptom relief,
  spiritual and psychosocial support to from
  diagnosis to the end of life and bereavement.
  Palliative care
• provides relief from pain and other distressing
  symptoms
• affirms life and regards dying as a normal
  process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual
  aspects of patient care
• offers a support system to help patients live as
  actively as possible until death
• offers a support system to help the family cope
  during the patients illness and in their own
  bereavement
• uses a team approach to address the needs of
  patients and their families, including
  bereavement counseling, if indicated
• will enhance quality of life, and may also
  positively influence the course of illness
• is applicable early in the course of illness, in
  conjunction with other therapies that are
  intended to prolong life, such as chemotherapy or
  radiation therapy, and includes those
  investigations needed to better understand and
  manage distressing clinical complications
• (World Health Organization/WHO _at_
  http//www.who.int/cancer/palliative)

63
The palliative care team provides access to
services such as

• Massage therapy
• Aromatherapy
• Acupuncture/acupressure
• Pet therapy
• Organic/holistic approaches to pain mgmt
• Deep breathing techniques
• Eastern Medicine (e.g. yoga, Thai Chi, herbal
  medicines)
• Counseling regarding physical/emotional coping
• Understanding legal or health care language
• Financial resources
• Note While palliative care specialists may not
  actually PROVIDE these services, they have the
  names/contacts of people who do! Most services
  require an MD order.

64
More about Palliative Care

• ANY health care professional can make a referral
  to the palliative care team or palliative care
  nurse
• Referring does NOT require an MD order
• It has been heralded for improving quality of
  life
• Hospice is under the palliative care umbrella,
  but it is NOT THE ONLY SERVICE PALLIATIVE CARE
  PROVIDES!
• Hospice is used when patients are terminal,
  usually having less than 6 months to live. It is
  usually covered by insurance.
• Palliative nurses are generally RNs. It is a
  specific type of nursing requiring specialty
  training.
• They are some of the coolest, most innovative
  people youll ever meet!
• Often have some quirky, untraditional methods of
  treating symptoms and side effects.
• They are direct, generally do not mince words
  and are usually well-seasoned folks who have lots
  of life experience.

65
Profile of a seasoned nurse An amazing asset to
any team!!!!!
66
Case Study Kris Circa Glioblastoma survivor
67
Kriss Story

• Elementary school teacher for 38 years
• 30 yrs in 5th grade/ 8 yrs in RSP
• Born, educated and grew up in Fullerton (and
  still lives there!)
• Hobbies shes a crafty lady! Wood working,
  tole painting, sewing, embroidery, scrapbooking,
  macramé, decoupage.
• LOVES to knit started in childhood and still
  doing it!
• Now makes caps for people suffering from
  traumatic hair loss (cancer, brain surgery,
  injuries, burns, alopecia).
• She has made 3395 of them since 2009!!!!!!!!
• Very active in an organization called Knots of
  Love
• Married x 35 years, no children. Mom is all who
  remains of her extended family.
• Kris is a breast cancer survivorTWICE! (1983
  and 1996)
• Reports having many wonderful friends though the
  years and having felt very secure, loved and
  accepted.
• Diagnosed with GBM of the R temporal lobe in
  2012. Currently undergoing treatment.

68
Knots of Love (www.knotsoflove.org)
                                                
                                           Knots
of love volunteers sorting through the Google
caps, as seen through Google Glass.
Knots of Love founder, Christine Fabiani
Knots of love volunteers sorting through the
Google caps
A nurse and veteran going through the bag of caps
Knots of Love founder Christine Fabiani delivered
to a Veterans Affairs hospital during last
years VA cap drive.
Photos/text compliments of The Newport Beach
Independent http//www.newportbeachindy.com/google
serve-week-benefits-local-charity/
69
Symptoms and Diagnosis in Kris words

• My symptoms began subtly. My dad and
  brother had migraines, so when I got a headache
  that lasted 6 weeks, I suspected I was joining
  the migraine club. On the Monday after
  Thanksgiving, 2012, as I was preparing to go to
  dinner with friends, I decided to lie down for
  "just a minute." My husband discovered me lying
  down, told me to put on shoes, and insisted we go
  to the Emergency Dept.
• From there, my memories get vague. I was
  admitted to the ICU after an MRI and awoke there
  the next afternoon after brain surgery. My
  husband and mother made the decision to proceed
  with the surgery as I was not aware at all. The
  neurosurgeon told my family that I had a large
  (egg-sized) mass in the right side of my brain.
  As it was glioblastoma, it was "a matter of life
  and death" so they gave the go-ahead, for which I
  am eternally grateful.
• The first time I saw the neurosurgeon was the
  day after the surgery. I have had an Oncologist
  for MANY years, so seeing her was not a shock.
  The surprise came in the Radiation Oncologist and
  what she had planned for me. I had 30 days of
  brain radiation, complete with "fencing mask",
  accompanied by oral chemotherapy. I had a
  re-growth of the tumor in 2013 but saw all the
  doctors prior to surgery that time.

70
St. Jude Medical Center, (SJMC) in Fullerton, CA,
where Kris went to inpatient neuro rehab post-op
Dr. Nowroozi, Kris physiatrist. and Medical
Director of Neuro Rehab at SJMC
Dr. Noblett, Kris neurosurgeon.
UCI Medical Center Irvine, CA where Kris had
her craniotomy and still receives treatment
71
Reaction to the C word

• Everyone I know cried, pulled up their
  grown-up pants, and decided to fight this thing.
  I have been completely surrounded by a safety net
  of love, support, compassion, meals brought in,
  folks driving me around, cards, phone calls, pep
  talks, and help.
• I had breast cancer in 1983 and 1996, so the
  "C" word was not too difficult for me, but I was
  most stunned that it wasn't metastatic breast
  cancer, rather a whole new mountain to climb. The
  most daunting part has been the statistics, cure
  rate (or lack thereof) and possibility of
  survival. I know 2 things miracles happen, and
  10 of people with this particular cancer
  survivor more than 5 years AND I intend to be in
  that group!

72
Medical Course

• After 7 days of recovery from surgery I was told
  I would be going to rehab, which I thought would
  be with older folks in diapers passing a beach
  ball around, or group sing-alongside. It turned
  out to be a positive experience, except that my
  life had totally left my control. I was given a
  daily schedule of physical, occupational, speech,
  recreational therapies, none of which I thought I
  needed! It turned out
  I was wrong and all were very
  informative and helpful.

73
Treatment and side effects

• While in the hospital, I was on anti-seizure
  medication (can't remember name) and steroids.
  When I came home I started Temodar orally, daily,
  in conjunction with radiation. That's when by
  blood (found) took a digger. They think it was
  due to suppression of my bone marrow from
  Adriamycin, Cytoxin, 5FU therapy for the breast
  cancer in the 80s. I received 3 transfusions of
  platelets and daily Nupagen (sp?) injections to
  try to bolster me up.
•  St Jude doesn't have a neuro-oncologist so I
  was referred to UC Irvine specialists to
  determine an alternate therapy. It was
  recommended that I use NovoCure TTF ( tumor
  treatment fields) along with Avastin infusions
  every other week.
• Note The most common seizure meds are Keppra
  (very expensive and not always covered by
  insurance) and Dilantin. Dilantin levels need to
  be monitored regularly when on this med.. You
  also cant drive while you have a dx of a seizure
  disorder.

74
                    
Temodar Also known as
temozolamide. Used to slow cancer growth
and/or shrink brain tumors. Also used w/ bone
cancers Side effects tiredness, headaches,
weakness, SEVERE nausea/vomiting. Can trigger
bone marrow cancer in some patients. Weakens the
immune system (anemia, nutropenia) and may cause
changes in clotting (thrombocytopenia).
Dangerous to mucous membranes if chewed or
inhaled. Precautions Do not eat prior to
treatment. Meds can be absorbed through the
skin Pregnant women shouldnt touch it. Use
soft toothbrushes to prevent gum bleeding. Avoid
contact with sharp objects. Take at the SAME
TIME every day. (www.webmd.com)
75
Avastin

• How it works Under normal conditions, new blood
  vessels grow to feed the tumor and help it grow.
  Avastin attacks the tumor at the vascular level,
  and prevents new vessels from reaching the tumor.
  This causes the tumor to stop growing and/or
  shrink.
• Most Common Side effects Nosebleeds, Headache,
  High blood pressure, Inflammation of the nose,
  Too much protein in the urine, Taste change, Dry
  skin, Rectal bleeding, Tear production disorder,
  Back pain, Inflammation of the skin.
  (www.webmd.com)

76
Kris Lingering effects/follow up

• Minor difficulties w/ balance, especially with
  the battery pack she has to wear on her back from
  the Novocure device. (The device actually weighs
  8 lbs, but feels like it