Photodynamic therapy (PDT)

This information is about photodynamic therapy (PDT). PDT is a treatment for some types of cancer. It may also be used to treat some non-cancerous conditions of the skin or eye.

• How PDT works
• When PDT is used
• How PDT is given
• PDT and possible side effects
• PDT for skin cancer
• PDT for cancers of the head and neck
• PDT for other cancers

How PDT works

PDT uses laser, or other light sources, combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy cancer cells.

A photosensitising agent is a drug that makes cells more sensitive to light. Once in the body, the drug is attracted to cancer cells. It does not do anything until it is exposed to a particular type of light. When the light is directed at the area of the cancer, the drug is activated and the cancer cells are destroyed. Some healthy, normal cells in the body will also be affected by PDT, although these cells will usually heal after the treatment.

When PDT is used

PDT may be used to treat cancers of the skin (but not melanoma), or those that are on, or near, the lining of internal organs, such as cancers of:

• the head and neck area
• the lining of the mouth
• the lining of the lung
• the lining of the gullet (oesophagus)
• the lining of the stomach
• the lining of the bladder
• the lining of the bile ducts.

Doctors are working to identify the types of cancer for which it is most effective. Research trials are taking place to look at new photosensitising agents, new laser and non-laser light treatments and ways of reducing the side effects.

Your doctor can advise you whether PDT is an appropriate treatment in your situation, and whether you may be able to take part in any research trials.

In cancers that are being treated at an early stage, the aim of treatment may be to try to cure the cancer.

The aim of PDT for advanced cancer is usually to reduce symptoms by shrinking the tumour. In this situation PDT cannot cure a cancer.

Photodynamic therapy treatments for some cancers, such as prostate and pancreas, are still the subjects of research. Some research studies have used PDT to treat conditions that may develop into a cancer, including one which affects the vulva known as vulval intraepithelial neoplasia (VIN).

PDT can safely be given to patients who have had other cancer treatments such as surgery, radiotherapy and chemotherapy.

How PDT is given

The treatment is normally in two stages.

Stage 1 A light-sensitive drug is given. For cancers of the skin, the drug is usually applied to the skin as a cream.

For cancers that are inside the body, the drug is usually given by injection into a vein.

There is a delay between the cream being applied, or the drug being given, and the next stage of treatment. This allows time for the drug to concentrate in the cancer cells.

Stage 2 The second stage of treatment involves shining light directly on to the cancer. A laser delivers energy in the form of light in a very precise way. Special non-laser lamps may also be used in some situations. For skin cancers, the light is shone directly onto the skin. For internal cancers, a flexible tube (an endoscope) may need to be passed into your body to deliver the light to the tumour.

PDT and possible side effects

As with all kinds of treatment, the experience of PDT can vary from person to person. How the treatment is given and the side effects that it may cause vary, according to:

• the area of the body affected by the cancer
• the type of photosensitising drug given
• the time between giving the drug and applying the light
• the amount of skin sensitivity to light following treatment.

When PDT is used to treat skin cancer, the side effects are different to when PDT is used for a cancer elsewhere in the body. For this reason we have divided this information into two: firstly for people being treated for skin cancers, and secondly for people with cancer in any other part of the body.

PDT for skin cancer

A photosensitising cream will be applied to the affected area of skin. You will then need to wait for approximately 4–6 hours before being treated. Treatment with the PDT light will last 20–45 minutes, after which a dressing will be put on to cover the area and protect it from light. Usually only one treatment is needed, but occasionally two or three further treatments may be given.

Possible side effects of PDT for skin cancer

• Pain You will be given a local anaesthetic before your PDT, to prevent pain. For many people this is all that they will need. You may be given steroid cream to apply to the area if it hurts when you are at home.

• Sensitivity to light The treated area of skin will be sensitive to daylight and bright, indoor lighting. This effect will probably last for between 24–36 hours. You will need to keep the treated area of skin covered during this time. After that you can wash, bathe or shower as usual, but you will still need to treat your skin gently and not rub the area until it has healed.

• Healing – a scab will form on the treated area The scab usually falls off after about three weeks. As PDT heals quickly without scarring, the appearance after treatment is usually very good.

PDT for cancers of the head and neck

The photosensitising drug is given as an injection through a small tube (cannula) inserted into a vein. This takes a few minutes and then the tube is removed.

You will then have to wait up to about four days before the light treatment is given. The length of time varies depending upon the particular photosensitising drug you've been given. Generally, only one treatment is given, although it is possible to have a second treatment a few weeks after the first.

Possible side effects of PDT for head and neck cancers

Sensitivity to light Although photosensitising drugs are mostly taken up by the cancer cells and are concentrated there, they can also make your ordinary skin cells, or your eyes, highly sensitive to light. People who have had PDT are advised to protect themselves from exposure to sunlight and bright indoor lighting. The duration of sensitivity to light (photosensitivity) varies depending upon which drug is used. The drug temoporfin (Foscan®) is commonly used to treat head and neck cancers and will make you sensitive to direct sunlight for up to two weeks.

While your skin is photosensitive, it is advisable to avoid going outside during the day. However, you do not need to stay in total darkness during this time. To start with you will need to stay in a darkened room, but you can gradually build-up the amount of light over two weeks. If you need to go out, use clothing to cover your skin: for example, wear a brimmed hat, scarf, long-sleeved shirt or blouse and trousers, gloves and dark glasses. Using sunscreens will not give you any additional protection.

You can go out uncovered very early in the morning or after sunset, and you can use low-level artificial light indoors (maximum 60W bulb). In the first few days it is possible to get ‘sunburn’ even on a dull winter day. You will not notice that you are getting burnt while you are out in the sun. As with sunburn, the damage to your skin can take a few hours to show up.

You can even get burnt through glass if the light is strong. Remember to draw curtains during the day if the sun is bright. Bright artificial lights can also cause a skin reaction, so spot lamps are best avoided. It is important to be aware of unexpected sources of light – for instance, warming your hands over a fire could result in being burnt. It is also a good idea not to use a computer during this time and not to watch the television from less than about 2 metres (6 feet) away. You may be given a light meter to use at home, to check that the light intensity is at a safe level.

It is advisable to avoid opticians’ appointments around the time of your treatment, as the retinas inside your eyes will be more vulnerable to light than usual, and you should not have light shone into your eyes.

Towards the end of the time of photosensitivity, a small area of skin can be exposed to brighter light for five minutes and the reaction assessed 24 hours later. Your doctors will advise you on how to do this. After this time, you will be able to gradually increase the amount of light you are exposed to and most people are able to go outside as usual after approximately three weeks. Your doctor or specialist nurse can let you know for exactly how long you will need to protect your skin.

Pain Treatment with PDT can cause pain in the tumour area. Your specialist nurse should be able to tell you how much pain you might expect and see that you are given appropriate painkillers. The amount of pain will vary according to where your tumour is and which light-sensitising drug has been used. Pain can range from mild to severe. For some treatments aspirin or paracetamol may be enough, however for others a morphine-type drug may be necessary. If you have pain, it is important to let your doctor know, so that you can be given effective and appropriate painkillers.

Swelling Some photosensitising drugs can cause swelling in the treated area. This varies from one person to another. If you have had treatment in your mouth or throat, the swelling may make it difficult to swallow. It is important to let your nurse or doctor know if swallowing becomes very difficult. The swelling is only temporary but can be treated with steroid injections or drugs that help to reduce inflammation.

Constipation This is a fairly common side effect of PDT and you may need to ask your doctor for medication.

Nausea Some people may feel sick, which can be controlled with mild anti-sickness tablets if necessary.

Healing PDT causes much less scarring than surgery. However, the time taken for PDT-treated areas to heal can vary a lot. It may be several weeks, depending on the area treated and how deeply the light has penetrated into the body tissues.

PDT for other cancers

Other than skin cancer, and cancers of the head and neck, the cancers most commonly treated with PDT are those found in the inner lining of the digestive system, the lungs and the bladder. However, as PDT is a new treatment, it may start to be used for other cancers. If the cancer is on the lining of an internal organ such as the gullet (oesophagus), stomach or lungs, it may be necessary for a thin, flexible tube to be passed into the windpipe or gullet to bring the laser light as close to the cancer as possible.

If the cancer is inside the bladder, a tube will be passed into the bladder. You would be given a drug to make you sleepy (sedated) while this part of the treatment is given.

There are several drugs that can be used as the photosensitising agent. The most common are 5-aminolevulinic acid (ALA), temoporfin (Foscan®) and porfimer sodium (Photofrin®). The drug used will depend on the type of cancer that you have and which is best for your situation. These drugs may be given as a drink or tablets or as an injection. The way that the drug is given will depend on which one is best for your treatment.

The length of time you need to wait for treatment after having the drug can vary from 90 minutes to four days. You will be told which drug will be used, how it will be given and whether your treatment is to be as an outpatient or if you will need to stay in hospital.

Possible side effects of PDT for other cancers

PDT drugs for cancers in other parts of the body are usually given by injection into a vein. Many of the side effects will be similar to those experienced by people who have had PDT for head and neck cancers. The time of sensitivity to light (photosensitivity) varies, ranging from one or two days to several months. This difference depends on which photosensitising drug is used. Your doctor or specialist nurse can let you know the length of time you will need to protect your skin.

You may also have some pain, nausea and constipation. Other side effects will depend upon the part of the body that is treated.

Cancer and pre-cancer of the gullet (oesophagus) Swelling and inflammation can occur around the treatment area and may cause nausea and chest pain. This may make swallowing difficult.

Cancer of the stomach The lining of the stomach may become inflamed and swollen, causing abdominal discomfort and nausea.

Cancer of the lung The PDT may cause swelling and inflammation in the lung which may cause some chest pain, a cough and breathlessness. You may notice that you are producing more sputum and rarely you may cough up blood-stained sputum. Occasionally there may be a build-up of fluid in the lining of the lung (a pleural effusion), which can be drained if necessary.

Cancer of the bladder It is likely that the PDT will cause symptoms of an inflamed bladder. Common problems include pain, the need to pass urine frequently, slight leakage of urine (incontinence), and passing small amounts of blood in the urine. These side effects usually last for only 2–4 weeks after treatment.

Cancer of the prostate PDT as a treatment for prostate cancer is still at an experimental stage. Possible side effects include mild incontinence of urine and difficulty passing urine.

Cancer of the pancreas PDT as a treatment for pancreatic cancer is still being researched and is not widely available. Possible side effects include abdominal pain and diarrhoea.

Hyperthermia treatment

This information is about the use of hyperthermia treatment in cancer. It is mainly used as part of research trials and is usually given with other cancer treatments such as radiotherapy (high-energy rays) and chemotherapy (anti-cancer drugs).

Hyperthermia is used to treat a number of different types of cancer. These include cancer of the gullet (oesophagus), stomach, breast, pancreas, cervix and rectum. It can also be used to treat melanoma, mesothelioma and some types of soft tissue sarcoma.

• Hyperthermia treatment
• How hyperthermia treatment works
• How the treatment is given
• Local hyperthermia treatment
• How local hyperthermia treatment is given
• Possible side effects
• Skin care

Hyperthermia treatment

Hyperthermia means an abnormally high body temperature. It is thought that heating areas of the body that contain a cancer, or heating the tumour itself, may help to kill cancer cells. This treatment exposes the body tissue to high temperatures, between 40°–45°C (104º–113ºF), without harming surrounding healthy tissue. The normal body temperature is 37°C (98.6ºF).

Hyperthermia treatment is mostly used to treat cancer that is localised in one part of the body. Giving hyperthermia treatment in combination with chemotherapy drugs or radiotherapy, or with both, may help to improve the effect of these treatments.

At the moment hyperthermia treatment is not available in the UK. It is available in Europe however, and a small number of patients in the UK may be able to have this treatment abroad through the NHS. Hyperthermia is suitable for breast cancer that has come back in the breast area (local recurrence).

How hyperthermia treatment works

Hyperthermia treatment destroys cancer cells by raising the tumour temperature. This is similar to the way the body uses fever to fight infection.

When normal body tissue is heated the blood vessels open up (dilate) to allow the blood to flow more freely. This helps to cool down the area and prevent damage. The blood supply to cancer cells is different. The blood vessels cannot dilate as well and blood flow is generally slower. When heat is applied to a cancer, the cells are less able to cool down and are more likely to be damaged by the high temperature. The effect of the heat damages the cancer cells and can deprive them of the nutrients they need to survive.

Hyperthermia treatment is almost always used in combination with either radiotherapy or chemotherapy.

How the treatment is given

How the treatment is given, and how much treatment is needed, depends on a number of factors. These include the part of the body affected by cancer and the size and shape of the tumour.

There are three ways in which hyperthermia can be given, depending on how much of the body needs treatment. These are known as local, regional and whole body hyperthermia. This information discusses local hyperthermia. If you would like information about regional or whole body hyperthermia, please contact our cancer support service nurses.

Local hyperthermia treatment

In local hyperthermia treatment, heat is applied to a small area only. This is done using applicators that are placed close to, or in, the tumour. There are different ways to deliver local hyperthermia: external; intraluminal (also called endocavitary); and interstitial. The method used depends on the type and position of the tumour.

External This is the technique that is used to treat breast cancer. It is also used for cancers that are on, or just below, the skin. The tumour is heated externally using applicators that are placed on, or near to, the affected area. Heat is then applied using high-frequency energy waves generated from a device outside the body (such as a microwave or ultrasound).

Intraluminal or endocavitary hyperthermia This may be used to treat cancers that are within or near to body cavities, such as the gullet (oesophagus) or rectum. A sterile probe that can be heated (a thin wire or hollow tube filled with water) is placed inside the cavity where the tumour is. This heats the affected area.

Interstitial hyperthermia This is used to treat tumours which are deep within the body, such as brain tumours. Under anaesthetic, probes or wires are placed within the tumour tissue and then heated. This method allows tumours to be heated to a higher temperature than external techniques.

How local hyperthermia treatment is given

You will lie on a bed or treatment couch and have a local anaesthetic to numb the area. Temperature monitors are applied to the area around the tumour. Thin plastic tubes (catheters) are then inserted into the tumour and small thermometers are placed inside the catheters.

To control the skin temperature, a water bag is placed on the area to be treated. The applicator (a small metal box which contains microwave radiators) is placed on the water bag. You will be awake during the procedure and asked to remain fairly still. During the treatment, members of staff are always nearby and will come and make adjustments to the position of the applicator. Each treatment can take up to an hour and a half.

During treatment, the staff will aim to get the temperature in the tumour as high as possible without damaging nearby tissues. The temperature will be measured continually and will be increased as long as you are comfortable. If you feel symptoms such as a burning sensation or a feeling of pressure on the area being treated, it is important you tell a member of staff. It may be that the temperature is too high and needs adjusting.

You might find that your whole body temperature starts to increase during treatment. You will be kept as comfortable as possible with air conditioning, wet towels and extra ventilation.

If you are having treatment for a tumour deep within the body, you will have your blood pressure and heart rate (pulse) monitored regularly and your temperature will also be checked.

You can have a relative or friend with you in the room during the procedure. If your companion has a pacemaker or is pregnant, however, they are not allowed to stay in the treatment room.

Possible side effects

Generally hyperthermia treatment is tolerated well with few side effects or complications.

During treatment you may feel a sensation of heat (like a hot water bottle). Heat applied directly to the skin can cause discomfort. It can also cause blisters, which usually heal within a few weeks.

Increasing the temperature of the treatment may cause the skin to burn or may cause muscle tenderness. The burn might result in a firm, tender spot below the skin. It will heal and usually the tenderness will disappear within a few days. This may cause problems, however, if you need further hyperthermia treatment.

Often people feel very tired after treatment. Usually the tiredness disappears after a few hours or following a night's sleep.

Skin care

If blisters develop during the treatment, it is important to treat the area with care. Try not to get the area too wet and avoid soaps, talcum powder and deodorant. Do not apply creams or dressings unless they have been prescribed or recommended by your specialist. Staff at the hospital will be able to give you advice on how to look after your skin.

Hyperbaric oxygen (HBO) therapy

This information is about the use of hyperbaric oxygen therapy (HBO) for people with cancer. HBO therapy is sometimes used to treat a number of severe side effects of treatment for cancer.

• HBO therapy
• What HBO therapy is used for
• How it works
• HBO therapy use in cancer
• When HBO therapy is used
• How HBO is given
• Possible side effects
• Less common side effects

HBO therapy

Hyperbaric oxygen therapy is a form of treatment which involves providing the body with extra oxygen. 'Hyper' means increased and 'baric' relates to pressure. Oxygen (O2) is one of the gases in the air that we breathe, and is essential for life. The air that we breathe normally contains 21% oxygen.

In HBO therapy, more oxygen is forced (pressurised) into normal air. (This can only be carried out in special chambers called hyperbaric oxygen chambers). People can breathe this increased oxygen by sitting in the chamber and using a mask or a hood.

Hyperbaric oxygen chambers were originally designed to treat deep sea divers for decompression illness (the 'bends'), and to treat severe carbon monoxide poisoning.

What HBO therapy is used for

HBO therapy can help in a number of different situations where body tissues have suffered from a decrease in oxygen levels. These include:

• decompression illness (divers who suffer from the bends)
• severe carbon monoxide poisoning
• smoke inhalation
• chronic wounds and some infections
• wound healing after reconstructive surgery
• radiation necrosis (body tissue dying off after radiotherapy treatment)
• acute blood loss where a blood transfusion is not possible (for Jehovah's Witnesses)

How it works

Oxygen is carried around the body by the blood. Breathing in 100% (pure) oxygen, under increased pressure (HBO), allows extra oxygen to be forced into the blood stream and dissolved at a far greater rate than if pressure was not used. This extra oxygen can help where healing is slowed down by infection or limited blood supply due to damage to the tissues. HBO therapy:

• encourages new blood vessels to grow and carry additional blood
• increases the ability of the body's defence mechanisms to fight infection and kill bacteria
• helps reduce any swelling that may occur around the area

HBO therapy use in cancer

Radiotherapy treatment for cancer can cause changes in the oxygen supply to tissues in the treated area. This is because radiotherapy affects normal cells and blood vessels as well cancer cells.

The small blood vessels in the treated area can be damaged by radiotherapy treatment, causing less blood to be supplied to that area. When this happens, it becomes more difficult for essential oxygen and nutrients to reach the tissues. Over a period of time, these affected tissues may deteriorate and become fragile. The tissues may break down and form areas of ulceration and, although not common, some tissues may eventually die off completely (radiation necrosis). These radiation injuries can occur very slowly over a number of months or even years.

Although HBO treatment has been available for a long time, its use for these effects of cancer is relatively new. More research into the use of HBO in treating the long-term side effects of radiotherapy is needed before it becomes more widely used in the UK. However, previous studies have suggested that HBO may be effective in the following conditions.

Chronic lymphoedema in breast cancer

Radiotherapy is often given after breast conserving surgery for breast cancer. A potential side effect of radiotherapy to the breast and armpit is lymphoedema (especially if all the lymph nodes have been surgically removed).

Lymphoedema is a swelling in the arm because of an abnormal collection of lymph in the body’s tissues. It can also cause pain and redness (erythema). It is thought that HBO therapy may help these symptoms by reducing the swelling in the area. Research trials are looking at how effective HBO therapy is in treating lymphoedema.

Chronic radiation cystitis

Radiotherapy is used as a treatment for some types of pelvic cancer. Sometimes treatment can lead to chronic cystitis (inflammation of the bladder tissues). Symptoms include urinary frequency (needing to go a lot), pain when passing urine, and blood in the urine (haematuria). These problems can occur months or years after treatment. Symptoms can be persistent and range from moderate to severe. HBO therapy may be used to help relieve things when other forms of treatment have been tried without success.

Osteoradionecrosis

Radiotherapy is often used for cancers in the head and neck. The tissues around this area are fragile and may break down after radiotherapy, particularly if previous surgery has been carried out. Although it is rare, the bone itself can be affected by radiotherapy and start to break down and die. This is known as osteoradionecrosis. It can also happen when radiotherapy is given to other areas of the body, such as the chest or the pelvis.

Treatment for osteoradionecrosis includes antibiotics, ‘washing-out’ the area with salty water (saline irrigation), and sometimes surgery to remove some or all of the affected bone. Although HBO therapy cannot restore the dead bone, increased oxygen can help the tissues around the area to heal by encouraging blood vessels to grow. HBO therapy can also be given before reconstructive surgery to help the healing process and prevent infection. If wounds or tissue are infected, treatment would usually consist of medicines or surgery as well as HBO therapy.

Tooth removal

Having a tooth removed shortly before, during or after radiotherapy treatment to the mouth and jaw area may increase the risk of osteoradionecrosis. This is because of the reduced oxygen supply to the area. HBO therapy can be given as a preventative measure, if used both before and after the tooth extraction, to stimulate the healing process.

Chronic radiation proctitis

Radiotherapy can be given for pelvic and bowel cancer. The rectum is very sensitive and although rare, long-term symptoms due to radiation damage can occur. These include pain, bleeding and irregularity in bowel habits. If these symptoms do not improve following treatments such as anti-inflammatory medicines, HBO therapy may be helpful.

When HBO therapy is used

Your doctor can refer you for HBO therapy if you have long-term side effects of radiotherapy that have not responded to normal treatment. Your consultant can advise you whether HBO therapy is appropriate in your situation.

HBO therapy is not always offered as a routine treatment for radiation damage, as it is a fairly new treatment in cancer care and knowledge about the potential benefits is not widespread. You can be referred for treatment by your GP or hospital specialist. Treatment is only offered at specialised centres throughout the UK, so you may have to travel some distance.

Before having HBO therapy you will be examined by a doctor to make sure that you are fit to receive this type of treatment. HBO therapy is not suitable for all people, and is not advised if you are pregnant, suffer from fits, or have severe chest disease or problems affecting your ears or sinuses. Treatment is not recommended if you have a fear of enclosed spaces (claustrophobia).

If you smoke, you may be asked to stop smoking before and during treatment as this is likely to affect the oxygen levels.

How HBO is given

Treatment is usually painless and is carried out in specially-designed chambers. There are two types of chamber: a monoplace chamber and a multiplace chamber.

A monoplace chamber is designed to treat one person at a time and involves lying on a 7ft padded stretcher that slides into a clear plastic tube (chamber) about 2ft wide. Once you are inside, the door is closed and the chamber is pressurised. You will be able to see and talk to a member of staff at all times during the treatment.

Multiplace chambers are designed to hold and treat several people (up to 12) at a time, and are more commonly used. These chambers are quite large and you will be able to walk about inside. Once you are sitting or lying inside the chamber, the doors will be closed and air is blown into the chamber to increase the pressure. You will hear a sound similar to that in an aircraft as the air begins to circulate. You will start to feel a sensation of fullness in your ears and will be shown how to ‘clear’ your ears. It is important to do this in order to equalise the pressure in the ears and to help prevent any pain in your ear drum.

When the pressure reaches the correct level, staff in the chamber will help you to put on either a mask or a clear hood to receive 100% oxygen. Trained staff usually stay with you throughout the treatment session and you can talk to staff outside as well should you need anything. You should be able to relax, read, or listen to music.

Near the end of the treatment the pressure in the chamber is gradually decreased over a period of time. You may feel popping in your ears during this time. After the decompression phase you can leave the chamber.

The length of each treatment varies depending on what you are being treated for and can last anywhere from 60–150 minutes at a time. Treatments are usually repeated over a number of days, or several weeks. For maximum benefit the entire course should be completed.

Treatment sessions are likely to be postponed if you are suffering from colds or flu, runny nose, cold-sores, nausea, vomiting or are generally feeling unwell. You should let your nurse or doctor know if you have any of these symptoms before starting a treatment session.

Possible side effects

HBO therapy is a relatively safe treatment with few serious side effects. Any side effects are usually minor and short lived. We have outlined the most common and less common side effects so that you can be aware of them. If you notice any other problems which you think may be due to the treatment, please discuss them with your nurse or doctor.

Blurred vision can occur after having multiple treatments and is due to the development of short sightedness (myopia). The effect usually comes on gradually and then gets better slowly when treatment ends. Temporary use of glasses or a change in prescription may be helpful, but the blurred vision only lasts a few weeks at most.

Light-headedness Some people feel light-headed after treatment. This only lasts for a few minutes.

Fatigue Tiredness is a side effect which can be more of a problem if you have treatment more than once a day. The effect usually wears off after a few days once the treatment sessions are finished.

Less common side effects

Ear problems Although rare, damage to the middle ear can occur due to the change of pressure. This can cause pain in the ears and bleeding if a rupture occurs. You will be shown how to equalise the pressure in your ear during treatment, which can help to prevent any ear problems.

Sinuses The change in pressure may cause congestion of sinuses, leading to headaches or facial pain. Usually this can be controlled with decongestant medicine but occasionally HBO therapy needs to be stopped.

Individual hormonal therapies by brand name

On this blog, drugs are referred to by their generic names. Sometimes, however, they are more commonly called by a brand name. This is an alphabetical list of brand names for hormonal therapies with links to the relevant information.

• Arimidex®
• Aromasin®
• Casodex®
• Cyprostat®
• Decapeptyl® SR
• Depo-Provera®
• Drogenil®
• Fareston®
• Farlutal®
• Faslodex®
• Femara®
• Gonapeptyl Depot®
• Megace®
• Prostap® 3
• Prostap® SR
• Provera®
• Stilboestrol®
• Suprefact®
• Zoladex® (Breast)
• Zoladex®, Zoladex® LA (Prostate)

• Anastrozole
• Bicalutamide
• Buserelin
• Cyproterone
• Diethylstilbestrol
• Exemestane
• Flutamide
• Fulvestrant
• Goserelin (Breast)
• Goserelin (Prostate)
• Letrozole
• Leuprorelin
• Medroxyprogesterone
• Megestrol acetate
• Tamoxifen
• Toremifene
• Triptorelin

Hormonal therapies: Overview

Hormones are substances that occur naturally in the body. They act as chemical messengers influencing the growth and activity of cells. Hormones are produced by a number of different organs or glands which together are known as the endocrine system.

Hormonal therapies act by altering the production or activity of particular hormones in the body. They are most commonly used to treat breast and prostate cancer. The type of hormone therapy given depends on the type of cancer being treated.

There are several different types of hormonal therapy. Our section on individual therapies provides more detailed information about each particular treatment.

patient information guide: Hormonal therapies

Book

Tamoxifen and breast cancer
Author	DeGregorio, Michael and Wiebe, Valerie J
Publisher	Yale University Press
Description	This book covers the history and evolution of breast cancer, how tamoxifen works, what the side effects are and why tamoxifen treatment is unsuccessful in some women.
ISBN	0300079516
Date	2000

Booklets and factsheets

Arimidex (anastrozole)
Author	Breast Cancer Care
Description	Factsheet no 19
Obtain from	Breast Cancer Care, Kiln House, 210 New King's Road, London SW6 4NZ Tel: 0808 800 6000 Email: info@breastcancercare.org.uk
URL	http://www.breastcancercare.org.uk/home

Aromasin (exemestane)
Author	Breast Cancer Care
Description	Factsheet no 30
Obtain from	Breast Cancer Care, Kiln House, 210 New King's Road, London SW6 4NZ Tel: 0808 800 6000 Email: info@breastcancercare.org.uk
URL	http://www.breastcancercare.org.uk/home

Individual hormonal therapies
Author	Cancerbackup
Description	Various factsheets
Obtain from	Online versions available Order from Cancerbackup

Tamoxifen
Author	Royal Marsden NHS Trust
Description	Leaflet
Obtain from	Hochland and Hochland Publications Ltd, 174A Ashley Road, Hale, Cheshire WA15 9SF Tel: 0161 273 4156 Fax: 0161 929 1818

Zoladex (goserelin)
Author	Breast Cancer Care
Description	Factsheet no 21
Obtain from	Breast Cancer Care, Kiln House, 210 New King's Road, London SW6 4NZ Tel: 0808 800 6000 Email: info@breastcancercare.org.uk
URL	http://www.breastcancercare.org.uk/home

Alternative therapies

• General information about alternative therapies
• Essiac
• Cow or shark cartilage
• Metabolic therapy
• Immuno-augmentative therapy

General information about alternative therapies

Alternative therapies means therapies which try to treat cancer with unconventional therapies instead of the usual medical methods. Although practitioners of these therapies may make claims that they can cure cancer or that they are effective in controlling symptoms, they cannot. Some alternative therapists use their therapies for people having conventional medical or complementary therapies.

Some alternative therapists advise that patients should give up conventional therapy to use alternative therapies. This can mean that patients with early cancer may miss out on treatments that could offer them a cure, and people with advanced cancer may miss out on conventional medicines that could control or reduce their symptoms.

Some therapies can be harmful and cause severe side effects. If you are thinking of trying an alternative therapy it is essential to talk to your cancer doctor or specialist nurse beforehand.

There are literally hundreds of alternative therapies – they include:

• Some dietary therapies such as Gerson therapy (see Diet)
• Alternative medicines
• Megavitamin therapy
• ‘Immuno-augmentative' therapy
• Cleansing therapies – such as intravenous hydrogen peroxide

Extravagant and sometimes convincing claims have been made about some alternative therapies in this section: for example, that they can cure cancer. However, there is no evidence that they can do so.

Essiac

'Essiac' is a herbal remedy originating from the Canadian native tribe, the Ojibwa. It was first publicised by a Canadian nurse called Renee Caisse. She named the remedy after herself - 'essiac' is her surname spelled backwards.

Essiac is a mixture of roots, bark and leaves, including burdock, sheep's sorrel and slippery elm. The mixture is boiled to form a brown liquid, which is taken as a drink. It is claimed to be a cure for cancer. Essiac is usually sold as a nutritional supplement. There have been reports over the years of cancers completely disappearing, although in many cases, it has been found that either the diagnosis was wrong in the first place, or that conventional cancer treatment is more likely to have been the 'cure'.

Essiac has been tested in trials in Canada and in the USA. The National Cancer Institute in the USA advises that Essiac does not appear to have any anti-cancer effect in the body, although it does not seem to do any harm either.

If you are interested in trying Essiac, talk to your doctor, as it can sometimes be used alongside your conventional cancer treatment.

Cow or shark cartilage

Cartilage is sold as a food supplement, rather than as a drug. It is taken as capsules or as a powder. Occasionally it is given as an injection just under the skin or as an enema (liquid passed into the back passage). The cartilage (tissue found between bones and joints) is taken from cows or sharks. In theory it is supposed to work by blocking the development of new blood vessels and starving the cancer. So far, scientific studies and trials have shown no evidence that it prevents or cures cancer. Doctors and researchers recommend that cartilage should only be taken as a cancer treatment as part of research trials. Cartilage therapy can cause side effects such as nausea and vomiting in some people.

Metabolic therapy

Metabolic therapy claims to boost the immune system. Metabolic therapists say that they diagnose abnormalities at the cellular level and correct them by normalising the patient's metabolism. They regard cancer, and other 'degenerative' diseases as the result of metabolic imbalance caused by a build up of 'toxic substances' in the body. They claim that they can treat the cause of the disease by removing 'toxins' and strengthening the immune system so the body can heal itself.

Metabolic treatments vary from practitioner to practitioner and may include a 'natural food' diet, coffee enemas, vitamins, minerals, enzymes, or chemicals. These are said to flush toxins out of the body, allowing it to heal. However, there is no research evidence suggests that these help in the treatment of cancer.

The most commonly used metabolic therapy in the UK is lætrile (amygdalin or vitamin B17), a derivative of bitter almonds. There are many websites which promote lætrile as a substance that can cure cancer, however, studies giving lætrile to people with cancer have not shown that it can help to control or cure cancer. Some websites promoting lætrile advise that people taking it should not use any other type of cancer therapy. This is very worrying as for many people with early cancer, conventional treatment may cure it. If you are thinking of taking lætrile therapy, it is best to discuss this with your cancer specialist or one of the organisations listed.

Immuno-augmentative therapy

There are several different types of immuno-augmentive therapy. They are aimed at training the patient's own immune system to recognise and destroy cancer cells. However, none have been shown to have any effect on cancer and they can be very, very expensive.

One type of therapy used in Europe to boost the immune system in people with cancer is Iscador: an extract of mistletoe. It has been used by homeopathic doctors for patients with cancer (although it is actually a herbal medicine). It can be taken as tablets or by injection and a course is prescribed. However, no reliable studies have shown that it has had any effect on the progress of cancer in patients.

Diet and cancer

• Diet and cancer
• A healthy diet
• The Bristol diet
• Alternative diets
• Possible problems
• Emotional effects
• Vitamins, megavitamin therapy and cancer
• The Gerson diet
• Nutritional therapists

Diet and cancer

There are several well-established links between diet and the causes of cancer. In general, fresh fruit and vegetables and high-fibre diets are good for you and can reduce the risk of getting cancer. Diets based more on fish and chicken and less on red meat may also reduce the risk. A high intake of smoked food may slightly increase the risk of some cancers. It is thought that diet plays a part in the development of up to a third of all cancers. However, there is no scientific evidence that once you have got cancer, eating a particular diet can treat the cancer or reduce the risk that it may come back.

Although diet cannot cure or control cancer, eating a healthy diet can improve general health and can help to give people a sense of control over their life and their future, which can be very beneficial. Your doctor, specialist nurse or dietitian can give you advice on healthy eating.

Whether or not you decide to change your diet may also be affected by your family's views. Families who are coping with the stress of a relative with cancer may add to the pressures on themselves by suddenly becoming vegetarians, or trying to get used to herbal teas. It is important to balance your doctor's or dietitian's advice with common sense.

A healthy diet

The basic principles of a healthy diet are:

Watch your weight

Try to maintain your weight within the normal range for your height (your GP can advise you on your ideal weight).
eat plenty of fresh fruit and vegetables

• eat foods high in fibre – such as wholemeal bread and grains
• eat more fish and chicken and less red meat
• eat less fat
• eat less sugar and salt
• have only moderate amounts of tea and coffee
• take time to eat slowly, peacefully and with enjoyment.

Be sensible with alcohol

Current sensible drinking guidelines recommend that:

• men drink no more than three units of alcohol per day, or 21 per week
• and women drink no more than two units per day, or 14 per week.

One unit of alcohol is the equivalent of a small glass of wine (125ml), half a pint of standard strength beer or lager, or a single measure (25ml) of a standard strength spirits.

These guidelines do not apply to people who have lost a lot of weight. They may need to eat whatever foods they can manage in order to get enough calories and protein. There may be times when someone with cancer wants to eat foods that are considered unhealthy but are very enjoyable. In this situation it is sensible not to be too rigid about a healthy diet.

Many complementary therapists do not recommend strictly vegan or vegetarian diets but are convinced that a good diet can be helpful. They create special diets, with the help of the person with cancer, which are as nutritious and enjoyable as possible.

The Bristol diet

The Bristol diet, developed at Penny Brohn Cancer Care (formerly Bristol Cancer Help Centre), is a type of complementary diet therapy. It is perhaps the best-known diet in the UK for people with cancer. The emphasis of this diet is on wholefoods; fresh fruit and vegetables; raw cereals; and organic fish, poultry and eggs. The diet stresses the avoidance of dairy produce such as milk, cheese and yoghurt, red meat, salt, sugar and caffeine (e.g. tea and coffee) and encourages the use of organically grown produce.

The diet can be modified to a person's individual needs, and the guidelines recommend that changes should be made gently and without pressure. They emphasise that eating should be enjoyable and not stressful. You can get information about the Bristol diet from Penny Brohn Cancer Care.

Alternative diets

There has been a lot of publicity about alternative diets for treating cancer over the past few years. Some alternative diets claim they rid the body of toxins that accumulate from the food we eat in the Western world. Many of these dietary therapies are strictly vegan or vegetarian. They involve eating food that is raw, sugar-free and low in salt. Sometimes, vegetable/fruit/liver juices and high doses of vitamins/minerals/enzymes may be used. Some recommend taking large doses of vitamins.

Many dramatic claims for cures of people with advanced cancer have been made and it is completely understandable that people with cancer should be attracted to diets which seem to offer the hope of a cure. However, there is no scientific evidence that alternative diets can make a cancer shrink, increase a person's chance of survival or cure the disease. As these diets have not as yet been properly studied, their real effect is uncertain.

There is increasing evidence that the right diet can help to reduce the risk of cancer. However, there is no scientific evidence that cutting out key elements of a normal diet, as some diet therapies advise, will improve the outcome for people once they have cancer.

Possible problems

Cancer doctors and dietitians are concerned that many alternative diets are completely inappropriate for most cancer patients. They can be high in bulk, and low in calories and protein, which can cause weight loss. Weight loss may be a particular problem if people have already lost weight from the cancer itself or its treatment. They then need all the protein and calories they can get, from whatever source.

Some people get pleasure and satisfaction from preparing these special diets, but others find them quite boring and even unpleasant to eat and time-consuming to prepare. Some of the alternative diets are very expensive. Some may even be harmful to people with cancer.

Emotional effects

People can also feel very angry and let down if they are led to believe that a particular diet will cure or control their cancer and this does not happen. They can also feel that they are to blame for not following the diet properly or because they did not believe in it enough.

It can be very confusing to be faced with conflicting advice about what to eat, but most doctors and specialist nurses recommend a well-balanced diet and one that you enjoy.

If you have any queries about alternative diets, or are thinking of following one, get further advice from your doctor, specialist nurse or dietitian.

Vitamins, megavitamin therapy and cancer

As the body cannot make vitamins in large enough amounts, they are an essential part of a healthy diet. Tiny amounts of certain vitamins help to protect the body from cancer. Therapists who recommend very large doses of vitamins (megavitamin therapy) in both preventing and treating cancer have tended to assume that if a little of a vitamin will do you good, a lot will be even better. However, there is no evidence that taking large doses of vitamins is helpful in treating cancer and recent research has shown that high doses of vitamins may be harmful.

The best way to get the vitamins and minerals you need is by eating a healthy diet.

The vitamins most often used in megavitamin therapy are vitamins A, C and E.

Selenium is a mineral trace element which can be found in brazil nuts, grain, fish and meat. There is some suggestion that selenium may protect against cancer. However, it is poisonous if taken in large doses.

Vitamins used in megavitamin therapy

• Vitamin A There is some evidence to suggest that vitamin A may have a protective action in some forms of cancer. However, very high doses can be harmful.
• Vitamin C Vitamin C is the most popular of the vitamin supplements used for cancer. It is said to reduce the spread of cancer cells and boost the immune system, but this has never been proved.
• Vitamin E This is also thought possibly to help prevent cancer. But as yet there is no reliable evidence to suggest it can help treat cancer.
• Vitamin Q10 is also sometimes used in this treatment. It has been suggested that there are molecules in the body called free radicals, which may damage cell membranes, and that these changes to the cell membrane are part of the development of cancer. It has been claimed that vitamin Q10 prevents this damage. However, there is no scientific evidence to support such claims.

The Gerson diet

The Gerson diet was created by a German doctor: Dr Max Gerson. He claimed a 50% recovery rate with his diet, even with people who were terminally ill, but there is no evidence at all to support this. The diet itself is strictly based on organic fruit and vegetables, taken mainly as juice prepared with a juice extractor. In addition a number of medications including thyroid hormones and liver extracts are given, and coffee enemas are used to ‘flush out toxins'.

This diet needs a lot of time and commitment and may be expensive to follow. Although there is no scientific evidence to support this, some people say that the Gerson diet has helped to reduce pain or other symptoms of cancer. Following the diet leads to an ‘allergic inflammation reaction' or ‘healing reaction' within 3–10 days. People who have used the Gerson diet have reported the following effects: nausea, vomiting, stomach cramps, a high temperature and headaches. Other possible side effects include perforation or rupture of the large intestine (colon) from using enemas, infections from the enema devices and serious fluid, electrolyte, and vitamin imbalances. The high levels of hormones and extracts used can lead to toxicity and may disrupt the metabolic balance in the body.

Nutritional therapists

Nutritional therapists focus on using diet as part of the healing process. They do not aim to cure a cancer, but try to improve the natural health of the body. A nutritional therapist will assess your general health and recommend a diet that is specific to your needs. There is no evidence that nutritional therapy can cure a cancer or reduce the chance of it coming back.

You can get more information about nutritional therapy and find a registered therapist from the British Association for Nutritional Therapy.

Psychological and self-help therapies

In this section, several approaches are discussed that have been used to help people cope with stress, anxiety and difficult feelings and emotions. They may be helpful for some people. It can also be helpful to develop open and honest communication between the person who has cancer, their family and friends, and their health professionals.

• Talking therapies
• Counselling
• Group therapy
• Self-help groups

Talking therapies

There are many different types of talking therapies available, including psychotherapy and counselling. These have all been shown to benefit people who have anxiety or depression, and can be useful for people affected by cancer. You can ask your doctor to put you in touch with the psychological support services at your hospital.

Counselling

Many people can get support by talking to close family members or friends, but it can sometimes be useful to talk to someone from outside your circle of family and friends, who has been trained to listen and help you explore your feelings. The emotions you are feeling may be very tangled and confused. You may find them difficult to talk about and very hard to share with your friends or family.

Talking one-to-one with a trained counsellor in a more focused way is designed to help you sort out your feelings and find ways of coping with them.

Some GPs have counsellors within their practice, or they can refer you to a counsellor. A national cancer counselling service, The Cancer Counselling Trust, provides face to face counselling for people in London and telephone counselling for anyone outside London. One to one, couples or family counselling is available.

Group therapy

You may be given the chance to take part in group therapy, in which a trained therapist (counsellor or other professional) encourages a group of people to share their feelings and experiences with each other. This is different from a self-help group (see below), as the therapist leading the group will be aware of the individual participants' problems and will be able to guide the discussion so that everyone benefits.

Self-help groups

Organised groups, where people with cancer and their families meet others in a similar situation, can be helpful. Often this is the first opportunity that families have to discuss their experiences with other people living with cancer.

These groups can be a source of information and support and can provide an opportunity for people to talk about their feelings. Some groups are run by health professionals, doctors and nurses, counsellors or psychotherapists in a hospital. More commonly, people with cancer run the groups. They often offer different techniques and coping strategies, together with relaxation or visualisation, as well as practical information and emotional support.

If you are interested in joining a group, but are unsure about whether it would be helpful, you could try making some enquiries about it first, and go to a meeting to see what it is like. You may feel more comfortable if you take a friend or a relative along with you. But if you are uncomfortable with a group situation, you don't have to go again. You may find it more helpful to find someone you can speak with individually on a regular basis to support you.

Complementary medicines

• Homeopathy
• Herbal medicine
• Flower remedies

Homeopathy

Although homeopathy is not part of conventional treatment for cancer it is often used to try to improve the quality of life of people with cancer as an addition to conventional treatment. Homeopathy has been used for many years for a wide range of illnesses, and the number of people using it to relieve cancer symptoms has steadily increased in recent years.

Homeopaths use homeopathy to help with a range of symptoms caused either by the disease itself or by the side effects of some of the conventional treatments such as radiotherapy and chemotherapy. They aim to help the body to find its own way of healing itself.

Homeopathy is based on the theory that a substance which causes similar symptoms to those of the illness being treated can be used in tiny amounts to treat those symptoms. Homeopathic remedies, which come in tablet form, liquid or creams, contain very diluted forms of these active ingredients.

Some GPs and hospital doctors are trained in homeopathy, and homeopathy is sometimes available through the NHS. If you are interested in this type of treatment you can discuss it with your GP or your cancer doctor.

You can get information about homeopathy and finding a registered practitioner from the British Homeopathic Association or The Royal London Homeopathic NHS Trust.

Herbal medicine

Herbal medicine is the use of plants or mixtures of plant extracts to treat disease. Herbs were commonly used in the UK before the development of modern medicines and they are still widely used by many people for common illnesses. In the UK there are also practitioners of Chinese medicine who use herbs as part of traditional Chinese medicine. The herbs are usually boiled up and drunk as a tea or tincture, but they can also be given as tablets, creams or ointments.

Herbal medicines aim to improve the natural functions of the body and restore a natural balance of health. They may help to reduce symptoms of cancer and the side effects of treatment.

If you are interested in trying herbal medicine, first check that the therapist is properly qualified, then talk to your cancer doctor. Some herbal medicines may contain substances that could be harmful to some people with cancer, such as arsenic, steroids or oestrogen. Some doctors are cautious about patients using herbal medicines because they are unsure of their effects and possible interactions with other medicines you may be taking.

It is important to check out carefully with your doctor any herbal medicines you are thinking of taking, as many herbal remedies are misleadingly promoted as cures for cancer.

You can get more information about herbal medicines and finding a registered practitioner from the National Institute of Medical Herbalists or the College of Integrated Chinese Medicine.

Flower remedies

Bach flower remedies

These remedies are based on the essences of flowers, diluted many times and drunk as a liquid. They are considered to be harmless and some people say that they help to reduce psychological and emotional symptoms. Bach flower remedies can be bought from health-food shops and some chemists. The remedies are often diluted in alcohol and so people who do not drink alcohol may choose not to use them.

You can get more information about Bach remedies from The Doctor Edward Bach Centre.

Other types of flower remedies such as Jan de Vries flower remedies are also available from chemists. They are considered to be harmless, and may help to reduce anxiety and some symptoms for some people.

Physical therapies

This section discusses eight physical therapies; massage, aromatherapy, reflexology, acupuncture, shiatsu, tai chi, qigong and yoga. These therapies are available to patients in some cancer hospitals for relieving symptoms and reducing anxiety. It is important that if you have these therapies outside the hospital, you always make sure the therapist or practitioner is trained and registered.

• Massage
• Aromatherapy
• Acupuncture
• Reflexology
• Shiatsu
• Tai chi and Qigong
• Yoga

Massage

Massage is one of the oldest therapies in existence. It is now often offered as part of cancer care in hospital wards, hospices and some GP surgeries.

Massage is a form of structured or therapeutic touch which can be used to relax, to relieve muscle pain and tension, and to bring comfort through contact with another human being. There are many different types of massage therapy. Some types are soft and gentle; other types are more vigorous and possibly uncomfortable.

Massage can help to reduce feelings of anxiety, hopelessness and despair. Some people worry that massage could cause spread of cancer cells, but research has shown that it is safe for people with cancer to have massage. However, it is important that the massage therapist avoids any area affected by the cancer.

Relatives or friends can be taught to massage the person who is ill, which can reduce anxiety and bring comfort to both people. Massage can be a form of communication between the massager and the patient, as well as relieving pain and muscle tension. As long as you are careful to avoid wounds or scars, vein thromboses (blood clots) and areas of tenderness, and to be particularly gentle if the cancer has spread to the bones, massage for people with cancer is very relaxing.

You can get more information about massage and finding a trained massage therapist from the General Council for Massage Therapy.

Aromatherapy

Aromatherapy is the use of scented natural oils extracted from flowers, plants or trees. The oils are thought to have therapeutic properties. They may be used during massage, but can also be used in special aromatherapy burners or in baths.

Different oils have different effects: for example, an aromatherapist may use cedarwood for a pleasant and relaxing effect, or rosemary for an invigorating and refreshing effect.

Some oils can have physical effects on the body, such as raising blood pressure, so it is important to tell the therapist about any medicines you take and give them all your medical details. If you are having conventional therapy for cancer, for example, chemotherapy, you should always check with your doctor before beginning aromatherapy treatment.

It is not always necessary to remove clothing to have massage or aromatherapy. Often hand and forearm massage or head and neck can be very relaxing.

For more detailed information about aromatherapy and to find a trained therapist, contact the International Federation of Professional Aromatherapists; they have guidelines for aromatherpists working with people who have cancer.

You could also contact the International Federation of Aromatherapists or the Aromatherapy Consortium.

Acupuncture

Acupuncture is based on traditional Chinese medicine. It uses thin, sterile acupuncture needles inserted just below the skin to affect the flow of energy in the body. As well as the circulatory and nervous systems in the body, in Chinese medicine there is also a system of life force (energy) channels. The energy that moves along the channels is known as chi.

Acupuncture needles are placed along points in the energy channels to help release the flow of chi and restore health and balance in the body. Acupuncture can help with all sorts of physical problems such as pain, nausea and a sore mouth, and can also help to reduce fear and anxiety.

A professional acupuncturist may be a member of a team working in a pain clinic. Some doctors are trained in acupuncture. Studies show that during acupuncture the body releases endorphins, natural chemicals which can relieve pain, relax muscles and increase feelings of well being. It may help to reduce hot flushes caused by cancer treatment for some women with breast cancer and men with prostate cancer.

Acupuncture is sometimes used to treat side effects of cancer treatment, such as nausea. Seabands (acubands), which work on a similar principle, by applying pressure to a specific area of the wrist, may also be helpful.

You can get more information about acupuncture and finding a registered practitioner from the British Acupuncture Council or the British Medical Acupuncture Society.

Reflexology

Reflexology is a specialised form of foot or hand massage that is related to the Chinese practice of acupressure. The theory underlying this therapy is that different areas on the sole of the foot or palm of the hand represent and are connected to the body's internal organs.

Systematically putting pressure on points in the feet or hands is thought to stimulate the flow of energy along energy channels in the body. Some people find that symptoms such as pain, constipation and sickness can be relieved. Many people report that reflexology can help reduce tension and pain and may be able to help with some symptoms of advanced cancer and to improve energy levels.

You can get more information about reflexology and finding a registered practitioner from the Association of Reflexologists or the British Reflexology Association.

Shiatsu

Shiatsu is a Japanese form of massage. Like acupuncture it is based on the idea that good health depends on the balanced flow of energy through specific channels in the body called meridians. Pressure is placed on the appropriate meridians to help the person's energy regain its balance. The therapist may also gently stretch or massage areas of the body to reduce stiffness and soreness. Many people find shiatsu relaxing and re-energising, as well as easing pain and other symptoms.

You can get more information about shiatsu and finding a registered practitioner from The Shiatsu Society.

Tai chi and Qigong

Tai chi and qigong are two Chinese philosophies which aim to strengthen the vital force (chi) of the body.

Tai chi (pronounced tie chee) is an ancient Chinese practice that focuses on building strength, balance and flexibility through slow, fluid movements combined with mental imagery and deep breathing. It can improve people's general health.

Qigong (pronounced chee goong) – sometimes spelled 'Chi Kung' – is another Chinese exercise system. Through individual mental and physical exercises, practitioners build up their health and prevent illness by combining discipline of mind, body and the body's 'Qi' (vital force).

Both Tai chi and qigong can help generate a sense of well being and peace and can reduce pain. The slow, graceful movements increase strength and flexibility and improve balance and circulation. They may also relieve some of the side effects of cancer treatment.

You can get more information about Tai Chi or Qigong and local classes from: www.taichifinder.co.uk and www.qi.org

Yoga

There are many different schools and styles of yoga, but they all encourage balanced and holistic development through the practice of yoga postures (asanas), breathing exercises (pranayama) and relaxation techniques.

The Sanskrit word yoga is translated as union between mind, body and spirit, and the practice aims to lead to a better balance of mind, body and spirit. Some types of yoga involve very gentle stretching, movement and meditation. Other types of yoga may involve more vigorous physical movement and dietary changes.

Some hospitals offer yoga as part of their complementary therapy programmes.

You can also get information about local classes from the British Wheel of Yoga.

Mind therapies

• Relaxation
• Relaxation exercises
• Visualisation (mental imagery)
• Hypnotherapy (hypnosis)
• Art therapy
• Healing
• Reiki
• Meditation

Relaxation

Simple breathing and relaxation exercises are very useful in reducing anxiety and stress and reducing the harmful effects of stress on the body. Almost everyone can learn the techniques.

They can quickly reduce anxiety and muscle tension and also affect the part of the nervous system that controls blood pressure and the digestive system. Many people with cancer, and their relatives, can be helped to relax and experience a sense of calmness using these simple methods. Relaxation may sometimes be used together with meditation and visualisation.

You can learn relaxation techniques at home using a CD or cassette, or you may be able to join a group. Self-help exercises need motivation and constant practice to give benefit, and it may be easier to stay motivated by attending group classes.

Lying flat may be uncomfortable for people who are breathless or in pain, but many relaxation exercises can be done sitting up or using pillows for support.

Some hospitals and support groups offer relaxation sessions. You can ask if they are provided at your hospital. Cancerbackup can give you details of support groups in your area.

Relaxation exercises

Two simple exercises are described below.

Exercise 1

Find a quiet room where you will be undisturbed for about 10-15 minutes. Undo any tight clothing and take off your shoes, then lie down on the bed or floor. Spend a few moments settling yourself down.Close your eyes, spread your feet 12-18 inches apart and check that your head, neck and spine are in a straight line.

Now focus your attention on your breathing. Do not try to change your breathing for the moment. Become aware of how quickly or slowly you are breathing. Notice whether there are any gaps or pauses between your breathing in and breathing out.

Pause

Now put one hand on your upper chest and one hand on your abdomen (tummy) just below your rib-cage. Relax your shoulders and hands. As you breathe in, feel your abdomen expand. As you breathe out, allow your abdomen to flatten. There should be little or no movement in your chest. Allow yourself a little time to get into a regular rhythm.

Pause

It may help to imagine that as you are breathing in, you draw half a circle with your breath and as you breathe out, you complete the second half of the circle.

Pause

Allow your breath to become smooth, easy and regular.

Pause

Now consciously slow down your breathing out and allow your breathing in to follow smoothly and easily.

Pause

If any distractions, thoughts or worries come into your mind, allow them to come, then allow them to go and bring your attention back to your breathing.

Pause

When you are ready to end this exercise, take a few deeper breaths in. Move your fingers and toes gently.

Exercise 2

Find a quiet room where you will be disturbed for 10-15 minutes. Take off your shoes amd loosen any tight clothing. You can do this exercise sitting, but it is better to lie down on a bed or carpet if you can. The exercise involves tensing and relaxing muscle groups in the body. If some of your muscles are uncomfortable or painful due to your cancer or treatments you have had, you may need to exclude these muscles from the exercise.

Close your eyes gently. Make sure your head, neck and spine are in a straight line. Start by raising your eyebrows and tensing the muscles of your forehead. Hold the tension for a count of five, then relax the muscles and become aware of any difference you feel in the muscles. Repeat once more.

Now squeeze you eyes shut,as tight as you can. Count to five, then release. Notice any difference. Repeat once more.

Open your mouth wide, stretching the muscles of your face. Count to five. Release. Repeat once more.

Tighten the muscles of your jaw, clenching your teeth. Count to five, release and repeat once more. Become aware of all your face and any difference you feel.

Raise your shoulders to your ears, tensing the muscles of your shoulders and neck. Release and relax the muscles. Notice any difference and repeat once more.

Raise your left hand and arm off the floor/bed. Make a fist and increase the tension in your hand, forearm and upper arm. Count to five and let go, allowing the hand to fall back on the floor/bed. Notice any difference between your left and right hand and repeat once more. Repeat the same with the right hand and arm.

Now contract the muscles of the chest. Notice the effect it has on your breathing. Relax. Flatten and tighten the muscles of your stomach. Count to five. Relax and breathe out.

Lift your left foot and leg off the floor by about six inches. Push your foot away from you,tensing the muscles of the foot, leg and thigh. Count to five. Let go and allow the leg to drop down on the floor/bed. Repeat once more on the left side. Then do the exercise twice on the right side.

When you are ready to finish, gently wiggle your fingers and toes - take a few deeper breaths in. Open your eyes gently.

Visualisation (mental imagery)

This is a technique that involves creating images in your mind while you are in a state of relaxation or meditation. For example:

• you might imagine that you are lying in a field full of beautiful flowers
• that you are healthy and strong
• that your healthy cells are knights fighting the cancer cells
• or that the suns rays are shining on you, warming you and giving you strength.

The theory is that by imagining a peaceful scene you will encourage yourself to feel more relaxed, and by imagining yourself as healthy you can influence the health of your body. A simple exercise to show how imagination can produce physical changes is to picture a lemon being cut in front of you. Most people who do this will notice that they start to produce more saliva.

Therapists who use creative visualisation in the treatment of cancer have suggested that you can stimulate the immune system to affect the growth of the cancer. Various research studies are being carried out to look at whether visualisation can improve outcomes for people with cancer. Some studies have shown that visualisation or guided imagery can reduce the symptoms of cancer and the side effects of treatment for some people.

Many people report that visualising themselves as stronger helps them to feel better, and they regard it as a form of extended relaxation. Some studies have shown that gentle mental imagery can produce significant improvements in the mood of people having treatment for breast cancer.

Some hospitals and support groups offer guided imagery or visualisation. You can ask if they are provided at your hospital or can contact Cancerbackup for details of support groups in your area.

Hypnotherapy (hypnosis)

Hypnosis is another method which some people find helpful in dealing with the symptoms of cancer. It can be especially helpful in reducing some of the side effects associated with chemotherapy and radiotherapy, such as nausea and vomiting.

In this treatment, the hypnotherapist leads the person into a deeply relaxed state, during which the person is still conscious of their surroundings. The hypnotherapist can then use suggestion to benefit the person in different ways, such as feeling better or gaining some control over symptoms.

You can find out more about hypnotherapy and how to contact a registered therapist from The British Society of Experimental and Clinical Hypnosis or the Central Register of Advanced Hypnotherapists.

Art therapy

This therapy is used to help people to express themselves through working with art materials. The art therapist is usually a psychotherapist and encourages the person to communicate feelings such as fear or anger through painting, drawing or sculpting. The aim is to express feelings rather than produce a work of art. The therapy can be given one-to-one with the therapist or in groups. Through creativity, we can sometimes become aware of and release pent-up feelings. The feelings or emotions can then be discussed, if appropriate, in counselling or group sessions.

You do not need to be able to paint well and you will be encouraged to be spontaneous and doodle. Sometimes the therapist may be more directive and ask you to ‘paint your cancer' or try to capture your relationship with your family. These exercises can help you understand yourself more fully. Art therapy can also be fun and a creative approach to dealing with unhappy and distressing experiences.

You can get more information about art therapy and finding a trained therapist from the British Association of Art Therapists.

Healing

Healers believe that healing energy exists all around us, and that they act as a channel through which healing energy flows into the patient. Healing can provide an important and very valuable support for the person with cancer and his or her family. It may be referred to as spiritual or faith healing if it is used in the context of a religious or spiritual approach to heal the person.

Contact healing may also be known as the laying on of hands in the Christian church.

In therapeutic touch the healer works just above the surface of the body; they believe this affects an energy field that surrounds each person. Some nurses practice therapeutic touch.

You can get more information about healing and finding a healer from the Confederation of Healing Organisations or the National Federation of Spiritual Healers.

Reiki

Reiki (pronounced ray-key) is a Japanese word meaning Universal Life Energy, an energy which is all around us. It is the name given to a system of natural healing which evolved in Japan from the experience and dedication of Dr Mikao Usui. Dr Usui was inspired to develop this healing system from ancient teachings after many years of study, research and meditation. He spent the rest of his life practising and teaching Reiki. Today Reiki is taught and practiced by Reiki Masters who have trained in the tradition passed down from master to student.

A Reiki treatment The recipient simply lies on a couch and relaxes. If they are unable to lie down the treatment can be given in a sitting position, the main thing is for the recipient to be as comfortable as possible. There is no need to remove any clothing. The practitioner gently places their hands non-intrusively in a sequence of positions which cover the whole body. The whole person is treated, rather than specific symptoms. A full treatment usually takes 1-1½ hours with each position held for several minutes.

Reiki treatment is offered in some hospitals and patient support groups.

You can get information about healing and finding a healer from The Reiki Association.

Meditation

Meditation is a way of working with the mind. It uses mental exercises which can help to deeply relax and calm the mind, helping to reduce feelings of fear, pain, anxiety and depression.

Regular meditation practice can help people feel more in control of themselves and their lives. Many studies have shown that regular meditation reduces the pulse rate, lowers blood pressure and reduces the level of stress chemicals in the body.

People who have particular psychiatric conditions such as psychosis may find that some types of meditation make their psychiatric illness worse. It is best to talk to a meditation instructor from an established meditation organisation (and your psychological support team, if necessary) before trying meditation. It is also helpful to practice in a group until you are familiar with the meditation technique. It is also good to talk regularly about your meditation to an experienced meditation practitioner.

Learning to meditate

There are many different types and styles of meditation. One type of meditation practice is described below:

You need to set aside some time - 10-20 minutes early in the morning or before you go to sleep at night. Find a quiet place in your home where you will not be disturbed. It is helpful to keep the same place for meditation as this reinforces the benefits of meditating. It also gives that place in your home a special significance.

The next step is to find a suitable chair or meditation cushion. Meditation is best practised sitting up. Of course you can meditate lying down on your bed, but you are more likely to fall asleep. Meditation is not sleeping - it aims to help you to be alert and awake. However, you can use some types of meditation to help you to go to sleep.

Choose a chair that is comfortable and has a straight back. You may like to support your back with a cushion or pillow. Keep your head, neck and spine erect. If your feet do not reach the floor comfortably, put a small cushion underneath them. If you prefer to sit on the floor, cross your legs in front of you in the most comfortable position and place a small cushion under your bottom.

Put your hands on your thighs. Be aware of your breathing. Spend a few minutes focusing your attention on your breath. Just breathe naturally - you do not need to try to control your breathing. Turn your attention to your forehead. Relax the muscles of your forehead. Relax the muscles of your eyes. Relax the muscles of your face. Check that your jaw is not too tightly closed and that your tongue is lying easily in your mouth. Relax your shoulders.

Relax your hands and fingers. Relax your chest and abdomen. Relax your thighs, knees, ankles and feet.

Bring your attention back to your breathing. Let the breath become smooth and even.

Pause

Now as you breathe in, the the word 'so' on your breath, silently, without moving your lips. As you breathe out, place the word 'hum' on your out breath, silently, without moving your lips. Continue to breathe smoothly and evenly, repeating the sounds 'so' and 'hum' as you breathe in and out. If any thoughts, worries or distractions come into your mind, allow them to come and then go, bringing your attention back to you breathing and the sounds 'so' and 'hum'. Continue for another 5-10 minutes, repeating the sounds internally in time with your breathing.

When you are about to stop, gently move your fingers and toes. Take a few deeper breaths in and out.

Some hospitals and support groups offer meditation sessions. You can ask if they are provided at your hospital or can contact Cancerbackup for details of support groups in your area.