Mayo Clinic Q&A podcast episodes that feature news, information and stories from our cancer experts and patients, hosted by Dr. Halena Gazelka.
Most Recent Episodes
Understanding pituitary tumors
December 13, 2022
Pituitary tumors are abnormal growths that develop in your pituitary gland. Pituitary tumors can cause too much or too little of the hormones that regulate important functions of your body to be produced. Most pituitary tumors are noncancerous growths called adenomas, which remain in your pituitary gland or surrounding tissues and don't spread to other parts of your body.
"It's very uncommon for any pituitary tumor to be a malignancy or what one would commonly think about as a cancer or something that would travel elsewhere," says Dr. Jamie Van Gompel, a Mayo Clinic neurosurgeon. "Almost all of these are benign tumors."
Pituitary tumors are categorized as functioning or nonfunctioning, depending on if they are producing hormones.
The signs and symptoms of nonfunctioning pituitary tumors, those that don't make hormones, nonfunctioning are related to their growth and the pressure they put on other structures.
"Out of all pituitary tumors, about half of them aren't making any kind of a substance," explains Dr. Van Gompel. "And those are called nonfunctioning adenomas or tumors. And they cause problems by putting pressure on things nearby. So they'll either take up enough room where the pituitary gland is so that it doesn't function well, and you have to get medications to replace some of that function. Or you may start to lose vision. That's another very common presenting symptom with these. "
Pituitary tumors that make hormones, called functioning, can cause a variety of signs and symptoms depending on the hormone they produce.
"Functioning tumors cause distinct syndromes," says Dr. Van Gompel. "The three most common are prolactin-secreting tumors, Cushing's and acromegaly."
Dr. Van Gompel explains overproduction of prolactin from a pituitary tumor can cause breast milk to develop in women, even when they aren't postpartum. In men, it often affects sexual function.
In Cushing syndrome, the body creates too much cortisol. The hallmark signs of Cushing syndrome are a fatty hump between the shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing syndrome also can result in high blood pressure, bone loss and, sometimes, Type 2 diabetes.
Acromegaly is a hormonal disorder that develops when the pituitary gland produces too much growth hormone during adulthood, causing bones to increase in size. In childhood, this leads to increased height and is called gigantism. But in adulthood, a change in height doesn't occur. Instead, the increase in bone size is limited to the bones of the hands, feet and face.
There are various options for treating pituitary tumors, including removing the tumor, controlling its growth and managing your hormone levels with medications.
Surgery often is needed if a pituitary tumor is pressing on the optic nerves or if the tumor is overproducing certain hormones. Most often, surgery is done endoscopically through the nasal cavity. The neurosurgeon removes the tumor through the nose and sinuses without an external incision. No other part of the brain is affected, and there's no visible scar.
Mayo Clinic is one of the largest pituitary centers in the U.S., evaluating and treating more than 1,600 people with pituitary tumors every year. Dr. Van Gompel explains that being treated at a referral center that sees a high volume of pituitary tumors is important.
"Here at Mayo, we have huge expertise, and a group of people that know how to manage these adenomas," explains Dr. Van Gompel. "We're fortunate to have excellent colleagues in neuroradiology because the imaging matters to help locate the tumors. We also have a team of endocrinologists who focus specifically on treatment and management of pituitary tumors. And we have surgeons, like me, who focus on adenomas. We're constantly working together studying our outcomes to make sure they're as good, if not better, than they were last year, to improve care for our patients."
On the Mayo Clinic Q&A podcast, Dr. Van Gompel discusses options for treating pituitary tumors.
Microsurgery can help treat lymphedema
December 6, 2022
One of the potentially painful side effects of cancer treatment is lymphedema. Lymphedema is tissue swelling caused by the buildup of fluid that's usually drained through the body's lymphatic system. Because lymph nodes are an important part of the lymphatic system, lymphedema can be caused by cancer treatments that remove or damage the lymph nodes.
"During cancer treatment, sometimes lymph nodes need to be removed, and the lymphatic system that travels around and through these lymph nodes, gets damaged as well," explains Dr. Antonio Forte, a Mayo Clinic plastic surgeon. "It's impossible to remove the lymph nodes without damaging the system."
Lymphedema most commonly affects the arms or legs, but can also occur in the chest wall, abdomen, neck and genitals. Severe cases of lymphedema can affect the ability to move the affected limb, increase the risks of skin infections and sepsis, and can lead to skin changes and breakdown.
An estimated 20% to 40% of patients undergoing an axillary lymph node dissection — removal of lymph nodes from the armpit, which is a common part of surgery for breast cancer — will develop lymphedema.
Nonsurgical treatment options include compression bandages or garments, massage, and careful skin care. If compression treatment isn't successful, a microsurgery technique, known as lymphovenous bypass, may be an option.
Microsurgery refers to the fact that the surgery is done using powerful microscopes that are magnified 20 to 25 times. Using special dye injected under the skin to identify the lymphatic pathways, surgeons then use small incisions to reroute the lymphatic system by connecting tiny lymphatic vessels to tiny veins, creating a detour around the damaged lymph nodes. The new connection restores the body's ability to drain lymphatic fluids.
Dr. Forte specializes in lymphovenous bypass surgery and has seen great benefits for patients. He points out that it's a minimally invasive procedure that can be done in an outpatient setting. The incisions are small, scarring is minimal, and patients can see significant reduction of their swelling.
"A very good study that was published almost a decade ago looked at patients that had lymphovenous bypass, and on average, 42% of the swelling improved over one year," says Dr. Forte. "Now there are patients that will have much more improvement than that. And some other patients will have very little improvement. But, on average, patients that have lymphovenous bypass surgery improve by 42%."
On this Mayo Clinic Q&A podcast, Dr. Forte explains the lymphovenous bypass procedure, who is a candidate for the surgery, and the risks and benefits of this lymphedema treatment.
Survivorship after surgery for lung cancer
November 15, 2022
More than 200,000 people in the U.S. will be diagnosed with lung cancerin 2022, according to the National Cancer Institute. A new lung cancer diagnosis can be scary and confusing, but having a support system can help.
"Probably the best advice I give patients with lung cancer is to build your village of support around you," says Dr. Shanda Blackmon, a Mayo Clinic thoracic surgeon. "Always see if you can have somebody come with you for your appointment, just to help you emotionally deal with things, to help you record what's being said, to help you collect that information, and then to also advocate for you."
If the cancer is confined to the lungs, surgery may be an option for treatment. Surgery is performed to remove the lung cancer and a margin of healthy tissue around the cancer site. Procedures to remove lung cancer include:
- Wedge resection to remove a small section of lung that contains the tumor along with a margin of healthy tissue.
- Segmental resection to remove a larger portion of lung, but not an entire lobe.
- Lobectomy to remove the entire lobe of one lung.
- Pneumonectomy to remove an entire lung.
The surgeon also may remove lymph nodes from a patient’s chest to check them for signs of cancer. The type of operation used for lung cancer treatment depends on the size and location of the cancer as well as how well a person’s lungs are functioning.
Dr. Blackmon recommends that patients explore all their surgical options.
"When you look at actual surgical options, you have minimally invasive surgery, or open surgery," explains Dr. Blackmon. "And the minimally invasive surgery has a lot of different options as well. Not every lung cancer surgery can be done minimally invasively. But if it can, certainly, the patient benefits."
Another important consideration is having your lung cancer surgery performed at a center that does a high volume of cases and is familiar with the type of procedure needed.
"When you go to have your car worked on — you go to the dealership that deals with your car specifically and someone who does it every day — they're going to be doing a better job than going to someone who's never even seen that type, make or model of car," says Dr. Blackmon. "I think we do that in life all the time. And it makes sense to do it in medicine, and in surgery especially."
After surgery for lung cancer, patients are often worried about short-term side effects, like shortness of breath and pain, as well as long-term worries about cancer recurrence. Both should be addressed as part of a cancer survivorship plan.
"Survivorship is part surveillance and part symptom management," says Dr. Blackmon. "The survivorship program here at Mayo Clinic really focuses on treating the whole patient. We have things like massage therapy. We have acupuncture. We have meditation. We have all kinds of resources that help patients to get their life back, get back in shape, and get all the parts of their body whole again as they start to heal from this really big surgery. But one thing that is so important is to continue to go back for that survivorship care with continued symptom monitoring and continued surveillance. That five-year period after the lung cancer surgery is so critically important."
On this Mayo Clinic Q&A podcast, Dr. Blackmon discusses what people can expect after surgery for lung cancer, and how to achieve the best quality of life.
Barrett’s esophagus requires monitoring and treatment to decrease esophageal cancer risk
November 8, 2022
Barrett's esophagus is a condition in which the lining esophagus becomes damaged by acid reflux, which causes the lining to thicken and become red. Over time, the valve between the esophagus and the stomach may begin to fail, leading to acid and chemical damage of the esophagus, a condition called gastroesophageal reflux disease, or GERD. In some people, GERD may trigger a change in the cells that line the lower esophagus, causing Barrett's esophagus.
"The stomach is well designed to handle highly acidic conditions," explains Dr. James East, a gastroenterologist at Mayo Clinic Healthcare in London. "But the esophagus is not designed to cope with acid. And so when acid comes up, that acid reflux damages the cells, replacing them with more acid-resistant cells that develop into Barrett's esophagus."
While frequent heartburn may be a sign, many people with Barrett’s esophagus have no symptoms. Having Barrett's esophagus does increase your risk of developing esophageal cancer. Although the cancer risk is small, it's important for people with Barrett's esophagus to have regular checkups to check for precancerous cells.
Those at highest risk for Barrett's esophagus include:
- White men over the age of 50.
- People with family history of Barrett's esophagus or esophageal cancer.
- People who smoke.
- People with excess abdominal fat.
- Patients with long-standing reflux lasting more than five years.
"If you have three of those risk factors, then you should have a screening endoscopy for Barrett's esophagus, according to current guidelines," says Dr. East.
To screen for Barrett's esophagus, a lighted tube with a camera at the end, called an endoscope, is passed down the throat to check for signs of changing esophagus tissue. A biopsy is often done to remove tissue and confirm the diagnosis.
Treatment for Barrett's esophagus depends on the extent of abnormal cell growth in your esophagus and your overall health. Treatments in the early stages can include lifestyle measures and medications to help reduce acid reflux and therefore, the esophageal acid exposure.
If the cell damage is more extensive, radiofrequency ablation may be be used. In this technique, a balloon is used to heat the abnormal esophagus tissue and burn it away. Another technique, cryotherapy, applies cold liquid or gas to destroy the abnormal cells.
The best way to prevent Barrett's esophagus is to address acid reflux and GERD through lifestyle changes.
"Lifestyle measures that reduce the risk of reflux are the key here because once Barrett's esophagus develops, it's a permanent change unless we use some of the ablation techniques," says Dr. East. "So absolutely quit smoking, and limit alcohol and caffeine. And even losing a small amount of weight can really help reduce reflux symptoms."
On the Mayo Clinic Q&A podcast, Dr. East discusses diagnosing and treating Barrett’s esophagus.
Advances in bone marrow transplant and cellular therapy
November 1, 2022
Mayo Clinic performed its first bone marrow transplant in 1963 and today hundreds of people receive blood and marrow transplants every year at Mayo Clinic in Arizona, Florida and Minnesota. Recently, Mayo Clinic in Rochester, Minnesota celebrated its 10,000th blood and marrow transplant.
Bone marrow transplant is used to treat blood cancers and related disorders by infusing healthy blood-forming stem cells into your body to replace unhealthy bone marrow. A bone marrow transplant is also called a stem cell transplant. Bone marrow transplants may use cells from your own body, called autologous transplant, or from a donor, known as allogeneic transplant.
Autologous stem cell transplants are typically used in people who are producing enough bone marrow but need to undergo high doses of chemotherapy and radiation to cure their disease. These treatments are likely to damage the bone marrow. Prior to treatment, healthy bone marrow cells are collected, frozen and stored for later use. After treatment, the stem cells are infused back into the patient to repopulate the bone marrow.
Allogeneic bone marrow transplant is used when there is underlying bone marrow failure syndrome or for certain types of bone cancers and blood cancers. In those cases, donor bone marrow is needed to replace the diseased bone marrow.
One common complication of allogenic transplant is developing graft versus host disease. This condition occurs when the donor stem cells see the body's tissues and organs as something foreign and attack them. Researchers have now discovered metabolic markers that can predict a person's risk for developing severe graft versus host disease, allowing for a more personalized treatment approach.
"Graft versus host disease occurs in patients that have had an allogeneic transplant from a donor," explains Dr. William Hogan, director of the Mayo Clinic Blood and Bone Marrow Transplant Program in Minnesota. "And this is where the donor immune system doesn't just recognize the leukemia that we're trying to treat — which is what we want — but it also attacks the patient's normal tissues. This can be anything from a relatively mild to a very devastating problem that can occur after transplant. And one of the challenges was that, by the time that has been fully developed, then it's harder to treat. So one of the goals of research in the last few years has been to develop markers that will tell us which patients are at risk of having the most severe graft versus host disease, and allowing us to target more effective treatment toward those patients."
Other recent advances in blood and bone marrow transplant include the use of mismatched donors and the ability to use bone marrow transplant in older, more frail patients thanks to improvements in antibiotics, antifungal drugs and other medications.
Another cellular therapy that is helping treat blood disorders and cancers is chimeric antigen receptor-T cell (CAR-T) therapy. CAR-T involves taking the T cells from a person and reengineering them to recognize and destroy cancer cells.
"CAR-T therapy is a very interesting therapy," says Dr. Hogan. "It's really come to fruition in the last five to 10 years. This is similar to bone marrow transplant, but not quite the same. It's a cellular-based therapy, so not a drug, but using cells that are modified in order to try and treat leukemias and other cancers. And basically, what it does is it takes our native immune system — and then the T cells specifically — and modifies them so that they are much more effective at recognizing targets that are on leukemia cells or other malignant cells. And that really kind of allows us to use the native immune system in a much more effective way of trying to kill leukemias."
Dr. Hogan says CAR-T therapy also is being developed for noncancerous conditions, like aplastic anemia, and research is looking at CAR-T as a treatment for a particular form of inflammatory multiple sclerosis.
"Things have really been transformed over the last five to 10 years with the advent of CAR-T therapy which has been groundbreaking," says Dr. Hogan. "The field of blood and bone marrow transplant continues to move forward, creating more effective treatments with less toxicity for many patients."
On the Mayo Clinic Q&A podcast, Dr. Hogan discusses advances in bone marrow transplant and cell therapy.
Proton beam therapy offers benefits to patients with breast cancer
October 25, 2022
The type of breast cancer a person has and how far it has spread determine the appropriate treatment. Previously, a patient with breast cancer might have received five to six weeks of radiation therapy.
But the approach is changing.
"For many years, we had the understanding that giving a little bit of radiation each day and spreading that treatment out over multiple weeks was the gentlest on the normal tissues, and that would lead to the least side effects," says Dr. Robert Mutter, a Mayo Clinic radiation oncologist. "But over the last decade or two, there's been a lot of research. We found we might be better off giving bigger doses each day and finishing in a shorter period of time. And that might be better at destroying the cancer cells, while limiting side effects of the normal tissue."
The use of proton beam radiation therapy is one way the treatment of breast cancer is advancing. Unlike traditional X-ray radiation, proton beam therapy can more precisely target tumors, sparing more normal tissue.
The Mayo Clinic Proton Beam Therapy Program uses pencil beam scanning, which Mayo investigators have shown reduces radiation exposure to healthy tissue. This highly targeted therapy is ideal for people with tumors close to or in vital organs, and for young people, whose organs are still developing.
Mayo Clinic offers proton beam therapy in Arizona and Minnesota. Recently, Mayo Clinic announced a $100 million gift from the Fred C. and Katherine B. Andersen Foundation to expand Mayo Clinic’s proton beam therapy services in Minnesota. “Protons have this ability to stop on a dime. And that's because they're charged, and they have a mass,” explains Dr. Mutter. “And so we can actually give them just enough energy to travel to the tissue and have them stop. And so all that tissue behind the tumor or the target is spared of radiation exposure. But we're very excited to be able to study proton therapy and to be able to offer proton therapy for patients that we think may benefit, including breast cancer.”
In this Mayo Clinic Q&A podcast, Dr. Mutter expands on Mayo Clinic's research and the development of new therapies to minimize patient side effects from radiation, including the increased use of proton therapy. Dr. Mutter also talks about the patient concerns about relapses and how Mayo is using medicines in combination with radiation to reduce relapse risks.
Hot chemotherapy for late-stage cancers
October 18, 2022
Hyperthermic intraperitoneal chemotherapy (HIPEC) delivers chemotherapy directly into the abdominal cavity. It is used in conjunction with cancer surgery for people with advanced cancer that has spread inside the abdomen. “Hyperthermic” means warm or hot. “Intraperitoneal” means inside the abdominal cavity, which is encased in a sac called the peritoneum.
HIPEC uses high-dose chemotherapy to kill microscopic cancer cells inside the abdominal cavity. The HIPEC procedure is performed immediately after a surgeon has removed all visible cancer in the abdomen. HIPEC is well studied in several types of cancer and being explored as a potential treatment in others.
"So really any cancer that's just localized in the abdomen on the surface of the peritoneum could be a candidate," explains Dr. Travis Grotz, a Mayo Clinic surgical oncologist. "We know for sure, based on studies and data that HIPEC works well for cancers of the colon, cancers of the appendix, cancer to the ovaries, cancer of the stomach, and there's even a cancer of the lining of the peritoneum, called mesothelioma. So those would be the cancers I think that are well studied and well accepted. Then, there are more rare tumors that we have less data for, such as cancer to the pancreas or gallbladder or small intestine, that we don't know yet if that's the right treatment."
The specific type of chemotherapy used for HIPEC varies depending on the type of cancer being treated. The abdominal cavity is bathed with hot chemotherapy to kill any microscopic cancer cells that might still be present. Heating the chemotherapy enhances its effectiveness because, when it’s hot, chemotherapy penetrates the tissue more deeply, increasing the number of cancer cells it can reach.
On this Mayo Clinic Q&A podcast, Dr. Grotz explains what HIPEC is, how it is performed, and the risks and benefits of the treatment.
Surgical options for breast cancer treatment
October 4, 2022
Most people diagnosed with breast cancer undergo surgery to remove their cancer from the breast as well as have lymph nodes removed as part of their treatment.
"Surgical resection of the tumor from the breast and also evaluation of the lymph nodes are used for the vast majority of patients with breast cancer, in particular, those patients where the disease is limited to the breast," says Dr. Judy C. Boughey, a surgical oncologist at Mayo Clinic. "One of the areas where often breast surgery does not have a role is if the breast cancer has spread or metastasized to other areas of the body. So for patients with stage 4 breast cancer, surgery has a much more questionable role."
Surgery is used to treat most stages of breast cancer, but it is rarely used to treat metastatic breast cancer — breast cancer that has spread to other parts of the body. Breast cancer surgery may be used alone or in combination with other treatments, such as chemotherapy, hormone therapy, targeted therapy and radiation therapy.
Breast cancer surgery includes different procedures, such as:
- Surgery to remove the entire breast (mastectomy)
- Surgery to remove a portion of the breast tissue (lumpectomy)
- Surgery to remove nearby lymph nodes
- Surgery to reconstruct a breast after mastectomy
Which breast cancer operation is best for an individual depends on the size and stage of the cancer, other treatment options available, and the goals and preferences of each patient.
For people with a very high risk of breast cancer, a preventive (prophylactic) mastectomy may be an option to reduce the risk of future breast cancer.
With so many options and decisions to be made, preparing for breast cancer surgery can be a challenge. It's important to be comfortable with your surgeon and to have the support of family and loved ones.
"Starting on the breast cancer journey is always a very challenging time," says Dr. Boughey. "Lean on your closest loved ones that you let into your inner circle and talk to them about your diagnosis, your treatment and your journey."
Dr. Boughey also encourages people to remember that everyone's journey is unique and to rely on your care team for trusted information.
"I think one thing to be very aware of with breast cancer is it is a very common disease, and every one of us knows someone or someone's relative that has been affected by this disease," explains Dr. Boughey. "Truthfully, breast cancer really is not one disease. And so I would just caution against hearing about your friends and their experience because it may have been a different size tumor and may have been treated a different way. And most importantly, it was likely a different tumor biology. And so you don't necessarily always have to listen to everybody's story and experience because that doesn't mean that yours will be the same. Share with your doctors some of the concerns that you've heard from your friends, from your colleagues, what you may have read on the internet, so that if they're not true, your team can dispel those myths for you and make you feel more comfortable."
On this Mayo Clinic Q&A podcast, Dr. Boughey discusses how surgery is used in the treatment of breast cancer.
Why are more people dying of uterine cancer?
September 20, 2022
The number of people who die from uterine cancer is increasing, particularly among Black women.
Also called endometrial cancer, uterine cancer begins in the layer of cells that form the lining, or endometrium, of the uterus. The American Cancer Society estimates that about 65,950 new cases of uterine cancer will be diagnosed in the U.S.this year, and about 12,550 people will die from the disease.
Researchers recently reported the results of a study of 208,587 women ages 40 and older with uterine cancer. The study showed death rates for all types of uterine cancer increased significantly by 1.8% per year from 2010 to 2017. Death rates remained stable for the most common form of uterine cancer — Type 1 endometrial cancer — but increased by 2.7% per year for a rarer, more aggressive form called Type 2 endometrial cancer.
"We do see a rise in diagnosis of uterine cancer," says Dr. Kristina Butler, a Mayo Clinic gynecologic oncologist. "And we feel like that is because there's also a rise of some other illnesses such as diabetes, hypertension and obesity, which are risk factors for uterine cancer. And because we're seeing more people experience those types of illnesses, uterine cancer rates are rising."
The study also revealed racial disparities in uterine cancer death rates. Death rates from uterine cancer increased 6.7% annually among Hispanic women, 3.5% among Black women, 3.4% among Asian women and 1.5% among White women. Despite representing less than 10% of cases, nearly 18% of all deaths from uterine cancer occurred in Black women.
"Addressing health disparities is a huge priority of our national organization, the Society of Gynecologic Oncology," explains Dr. Butler. "I think it's very clear that there are disparities as it relates to patient access to care. Also, opportunities to train providers in cultural competency, so that patients feel very comfortable coming and having that patient-doctor relationship. And we need to improve health care access for women in rural communities and take education to those communities so that those women feel comfortable reaching out to us when they need care."
On this Mayo Clinic Q&A podcast, Dr. Butler discusses uterine cancer, disparities related to the disease, and what people can do to reduce their risk of developing this type of cancer.
Raising awareness of childhood cancer
September 16, 2022
While childhood cancer is rare, 1 in every 266 children and adolescents will be diagnosed with cancer by age 20, according to the American Cancer Society. Each September, advocacy groups, health care institutions, patients and families recognize Childhood Cancer Awareness Month to help families who receive a cancer diagnosis.
“A lot of people still don't know what to do if a child is diagnosed with cancer or where to go,” explains Dr. Wendy Allen-Rhoades, a Mayo Clinic pediatric hematologist and oncologist. “We want people to know that we know that a cancer diagnosis is scary. We know that it’s life-altering. But we also want you to know that there's hope, that we are doing really good things here at Mayo Clinic and elsewhere. And there is hope for a cure, and there is life after childhood cancer.”
Dr. Allen-Rhoades says funding is needed for more pediatric cancer research to continue to improve treatments. One area of focus for her has been sarcomas. Sarcoma — the term for a group of cancers that begin in the bones and in the soft or connective tissues — is one of the more common types of childhood cancer.
Fortunately, recent treatment advances have increased survival rates. Of children diagnosed with cancer, 84% now survive five years or more. One of the advances in treatment has been improvement in radiation therapy techniques and the use of proton beam therapy to treat pediatric cancers.
"Radiation therapy works very well for sarcomas," says Dr. Wendy Allen-Rhoades, a Mayo Clinic pediatric hematologist and oncologist. "And the difference between conventional radiation and proton therapy radiation is that our radiation oncologists are able to contour a little bit tighter with proton therapy. Therefore, the surrounding tissue that is normal is spared from some of the side effects. This is really important in children who are growing because we want them to be able to grow normally."
In addition to sparing healthy tissue from the effects of radiation, people who must undergo radiation therapy early in life are less likely to have long-term side effects and complications, such as secondary cancers, with proton beam therapy than with conventional radiation therapy.
While treatments and cure rates for sarcomas have improved, Dr. Allen-Rhoades hopes for even better results in the future.
“Sarcomas have been a tough nut to crack for sure in terms of research and novel innovative therapies,” says Dr. Allen-Rhoades. “We still have a ways to go, but we're doing much, much better than we were 20—30 years ago. But until we can cure everyone, it will never be enough.”
On the Mayo Clinic Q&A podcast, Dr. Allen-Rhoades discusses pediatric sarcomas and the importance of funding for research and support of families dealing with pediatric cancer.