Some of you have been interested in the recent discussion of pharmacogenetic testing and have asked if it's available. Yes, it's available, but many psychiatrists aren't yet comfortable with interpreting the results.

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The Mayo Medical Laboratory began testing in 2003 to determine whether people could tolerate certain antidepressants. In a relatively short time, other large medical laboratories also began offering these tests.

Two things have happened to improve access to testing:

First, a company called AssureRx Health was created to provide the results of these tests to psychiatrists using a more "physician friendly" report. A psychiatrist can now collect just a simple cheek swab sample of DNA, send it overnight to AssureRx and receive the results electronically within 36 to 48 hours.Second, more than 2,000 psychiatrists have taken a Mayo Clinic course designed to help them use this testing more efficiently.

By incorporating new research results from ongoing scientific studies, the testing is getting increasingly more accurate. While the results still can't provide a certain prediction of which antidepressant will be most effective, the tests do increase the chances of identifying an effective medication and can definitely identify medications that you're unlikely to be able to tolerate.

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Before people develop type 2 diabetes, they usually have prediabetes or impaired fasting blood glucose. If your blood sugar level is over 100 mg/dL (5.5 mmol) but less than 126 mg/dL (7 mmol), you're considered to have prediabetes.

Prediabetes/diabetes has become a worldwide epidemic. There are 57 million people in the United States alone who have prediabetes and most don't know it, according to the American Diabetes Association.

Unfortunately, many people who believe they're "borderline diabetic" or have "a touch of diabetes" think that they're safe. However, research has shown that some long-term damage is being done to the body, especially to the heart and circulatory system.

You're overweight or obese. This can keep your body from making and using insulin properly. Being overweight can also cause high blood pressure.You have a parent, brother or sister with diabetes. If you have a relative with type 2 diabetes, this more than doubles your risk of getting the disease.You're African-American, American Indian, Asian-American, Pacific Islander or of Hispanic/Latino heritage.You had gestational diabetes or gave birth to at least one baby who weighed more than 9 pounds (4.1 kilograms).You have high blood pressure.Your HDL or "good" cholesterol is below 35 mg/dL (0.9 mmol/L) or your triglyceride level is above 250 mg/dL (2.83 mmol/L).You exercise fewer than three times a week.

You can have prediabetes and not know it. Two tests are commonly used to diagnose prediabetes:

Fasting blood glucose. Measures blood glucose first thing in the morning before you eat. A normal fasting blood glucose is between 70 to100 mg/dL (3.8 to 5.5 mmol). You have prediabetes if your fasting blood sugar is 101 to 125 mg/dL (5.6 to 6.9 mmol).Oral glucose tolerance test. Measures blood glucose after fasting and again 2 hours after drinking a glucose-rich drink. Normal blood glucose is below 140 mg/dL (7.7 mmol) 2 hours after the drink. In prediabetes, the 2-hour blood glucose is 140 to 199 mg/dL (7.8 to 11.0 mmol/L). If the 2-hour blood glucose rises to 200 mg/dL (11.1 mmol) or above, you have diabetes.

If you have prediabetes, you should do something about it. Studies have shown that people with prediabetes can prevent or delay the development of type 2 diabetes by up to 58 percent through changes to their lifestyle, including modest weight loss (as little as 5 to 7 percent of your current weight) and increasing physical exercise. That is huge!

- Peggy

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Pharmacogenomics is a new field of study in medicine. It involves the identification of genetic variations that predict the response of a patient to a medication. Pharmacogenomics is relevant for all types of drugs such as medications for asthma or hypertension. It's now possible to use pharmacogenomic testing to help select an antidepressant.

In a previous blog, I discussed the relationship between a variant of the serotonin transporter gene and vulnerability to developing depression when faced with severe stress. If you have the more active form of this gene, you're less likely to develop depression even if you find yourself in a stressful situation. However, if you have the more active form of this gene and do become depressed, you're more likely to get better if you take a selective serotonin reuptake inhibitor (SSRI) antidepressant like Prozac (fluoxetine), Paxil (paroxetine), or Celexa (citalopram).

The probability of a good response to an SSRI is particularly high if you identify yourself as being "white." This suggests that other gene variations that are more common in patients of European ancestry may also influence the response of these patients to SSRI's.

For several years, it's been known that patients with the more active form of the serotonin transporter gene are more likely to respond to SSRI treatment. However, it's only been possible to test patients to see whether they have a more or less active form of this gene for the past three years. Based on the results of this pharmacogenomic testing, a psychiatrist is now able to develop a better understanding of what the probability will be for a specific patient achieving a good clinical outcome. The primary goal of testing is simply to be able to avoid side effects and identify an effective antidepressant medication more quickly.

To be able to get an even more accurate prediction of response, it will ultimately be necessary to test more than any one single gene as many genes influence the probability of responding to treatment. As testing becomes more sophisticated, there's every reason to believe that treatment outcomes will continue to improve. For many of you struggling with depression, the fact that there are now many researchers working to better understand antidepressant medication response should provide some hope.

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Who should receive transcranial magnetic stimulation (TMS)?

Experience with TMS makes it clear that not all patients respond to this treatment, but it also demonstrates that some do.  The success rate varies as a consequence of a number of factors, but the type and severity of the depression makes a difference.

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TMS works best for patients with moderate depression who don't tolerate antidepressant medications.  TMS is unlikely to work if you've received electro-convulsant therapy (ECT) and weren't helped by it.

TMS is still a quite new treatment. Psychiatrists vary in their experience using it and their confidence in its effectiveness. The most attractive features of TMS are that it's quite safe and effective for some patients. The biggest drawbacks are that it doesn't help some patients, it can take several weeks to begin to work, and is quite expensive.

If you're struggling with depression, you must ultimately decide whether TMS is the right treatment. A decision should be made on the basis of a frank discussion between a knowledgeable psychiatrist and an informed patient.  Once you understand the potential benefits and risks as well as the cost, the decision should be made as to whether the potential gain is worth the cost. Beginning a new treatment is not usually an easy decision, but it should be a joint decision based on the available evidence.

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It makes sense that if the fuel we are providing for our body, National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)including our brains, is healthy, that our bodies will function more efficiently. We all know that diets higher in fiber, as well as low in saturated fats, contribute to better health overall.

We have talked about the link between depression and other medical illnesses many times. For instance, depression and heart disease are linked. Thyroid disease is another medical condition that can cause or contribute to depression. Your diet may be another link.

Eating a Mediterranean diet may lower the risk of depression by almost one-third, according to some research. The Mediterranean diet includes lots of fruits and vegetables, as well as whole grains and healthy fats and oils. This doesn't mean that diet alone is an alternative way to treat depression. But, it can't hurt to make healthier food choices each day. As always, please talk with your health care provider about specific treatment options for depression, including your diet choices.

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We talk about depression as if it were a single entity. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)This is clearly not the case. What we refer to as depression is actually many illnesses that are characterized by profound sadness. No one wants to be sick, but it's less disastrous to be sick if there's a treatment that that can effectively treat your condition.

For many of you with depression, when you take an antidepressant medication, you'll feel better. I conducted a study supported by the National Institutes of Health, rather than a pharmaceutical company, to try to identify which patients will respond to escitalopram, known as Lexapro, and which ones will not. We treated more than 600 patients with moderately severe depression. Half of the patients who took the antidepressant were feeling well within two months, and another 20 percent were feeling a lot better. Unfortunately, 30 percent were not much better.

If depression is a new problem, you have every reason to be optimistic you'll be among the 70 percent of patients who have a good response to antidepressant treatment. When an antidepressant does work, both you and your doctor are grateful.

However, a dangerous situation can evolve if a series of antidepressant medications don't work. If no medication provides relief after a reasonable number have been tried, it becomes clear that you're suffering from treatment-resistant depression and that another form of treatment needs to be tried. However, you should have the opportunity to try all of the classes of antidepressant medications before coming to the conclusion that medications won't help.

A really critical problem for many of you is that you can't get access to appropriate medical care. This is what healthcare reform should be about. Everyone should have access to effective treatments. Unfortunately, many still don't.

A final thought is that making a persistent effort to find an effective treatment usually results in success. For those of you who can't find help, this isn't comforting. However, for those who do have access to care, the odds of being able to feel well again are good.

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Depression can zap your confidence. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)Some days you may feel like you can't even follow through with the smallest of tasks. Being grateful can do wonders for your mood.

This doesn't have to be elaborate or detailed. I suggest that you write down three things each day that you're thankful for. This can be three sentences or three words, the simpler the better. Keep paper or a journal by your bedside and jot in it daily. This can be at bedtime or in the morning, whichever works best for you.

What's so nice about jotting down why you're being grateful is that it doesn't take a lot of effort and is very powerful. Looking back over what you've written can help you to evaluate and learn where you've been and who you have become. This is a simple, reasonable goal that you can accomplish. This will build up your sense of positive self worth. You can do it, and you deserve to invest in yourself.

Please share your thoughts.

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Depression can be a frustrating illness. Since the introduction of the first antidepressant medications more than 50 years ago, the process of finding the right medication to treat it has been one of trial and error. Given that it takes two to four weeks to have a good sense of whether a particular antidepressant will work, it can take several months to systematically assess a series of antidepressants in order to find one that's effective.

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After two or three trials that can take two to three months, most people become discouraged if they're still struggling with the symptoms of depression. The idea of trying a fourth or a fifth or even a sixth medication can seem like too much of a hassle. However, if one steps back from this disappointment, it's reassuring to remember that there are 18 different antidepressants currently available and prescribed. Many of the older ones are rarely used, but they can prove to be effective for a particular person.

Most people with severe treatment resistant-depression give up long before trying all of the available medications. That's why doing research to find a way to more efficiently identify the right drug for the right person at the right dose is so important.

In reviewing recent comments, it's clear that many of you who are treated with antidepressants and faithfully take your medication often have a good response that is followed by a relapse. Often the relapse occurs when you're experiencing increased stress and are feeling the most vulnerable. Your comments reflect the importance of staying in close communication with your physician. It also makes good sense to have a medical checkup at the time of a relapse as many medical and neurological illnesses can cause depression.

Once a medical cause for a relapse is ruled out, a sensible response is to consider raising the dose of the medication. Unfortunately, this is often done blindly based on the belief that it's not problematic to carefully push the dose up.

However, there are two strategies that a physician can use to minimize the risk of making things worse by escalating the dose. The old-fashioned way to do this is to get a blood level to check to see if there is the right amount of medication in the blood. Twenty years ago when the tricyclic antidepressants were popular, psychiatrists would routinely check the blood levels of amitriptyline (Elavil) or imipramine (Tofranil) before increasing the dose. In many places in Europe, psychiatrists still do monitor blood levels, but it's now relatively uncommon in the United States.

Today there's a more efficient method that can minimize problems that occur after increasing the dose. It's now possible to collect DNA by just rubbing a "cheek swab" on the inner surface of the cheek. The swab is then sent to a laboratory to determine your genetic metabolic capacity.

There are many examples of how this can help. One example is the use of paroxetine (Paxil). The usual starting dose is 20 mg, which may work well if you have a relatively low metabolic capacity because you'd have a quite high blood level at this starting dose. However, if depressive symptoms return, raising the dose to 30 mg will probably result in a very high blood level because you'd be unable to efficiently metabolize the medication. A blood level that's too high usually results in unpleasant side effects. In contrast, if you have a normal metabolic capacity you'd be unlikely to have severe side effects when the dose was increased by only 10 mg.

Many people feel like they've tried every antidepressant, but few have actually been prescribed 18 different medications. Of course, it's easy to be discouraged after even two or three failures, but persevering in the search for the right medication can pay off.

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Reading many of your postings reveals how many people are suffering from really crippling depression. National Suicide Prevention Lifeline
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1-800-950-NAMI (6264)While there are some encouraging posts, many others expose the intense pain that people with depression must learn to endure. It's also clear that family members often don't know how to help.

People with serious depression begin to lose hope. Unfortunately, so do the people who love them. Perhaps the greatest danger is to give up, so it's critical to keep trying to find some relief.

Of course, it's not easy to maintain hope when you feel that there is no hope. I've been a psychiatrist for many years. Taking care of patients with depression has taught me that most patients get better. A very important reason that patients get better is that we have better medications which work in a variety of different ways. While it's critical to find the right antidepressant, it's just as important to find a psychiatrist who you can begin to trust and who will help you to maintain hope.

Over the years, I've treated many teenagers who were miserable and wanted their lives to end. Their parents usually didn't know how to help, but found a way to get them the treatment that they needed. Many of these patients are now parents themselves and have found their path through life. I always appreciate getting a graduation announcement or news of a wedding because it provides me with strong evidence that I'm right to be hopeful.

It's very obvious that some antidepressants don't help some people. Fortunately, there are many medications that can be used to treat depression and it's usually possible to find one that does help. However, it often takes time and requires that your psychiatrist gets the dose right. It also requires that you don't give up.

If there is someone you love who is suffering from depression, there are some critically important things that you can do to help. The most important is to make sure they know that you care for them, even if they're convinced that they're unworthy of your caring. Being there for them is the most important thing that you can do. However, you also need to find a way to help them to find a psychiatrist who can work with them. Once that goal is achieved, it will be much easier for them to become hopeful.

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Our institution is in the midst of one of the largest construction projects in our history. It will involve years of construction and hundreds of workers. When you walk by the site, it's obvious that there's a tremendous emphasis on safety. Throughout the complex signs are posted that say safety is everyone's responsibility.

If the stress in your life is more than you can cope with, get help right away.

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Each worker is required to wear a construction-grade helmet, protective eyewear when appropriate, steel-toe shoes and a safety harness when working above ground level. Some of the work involves creating pedestrian tunnels, and those workers receive additional instruction in the high-risk aspects of the job.

This experience made me reflect that each of us works in high-risk situations. You may not use heavy equipment or be at risk of falling, but is your work environment one of stress, deadlines and demands that often exceed your resources?

The risks are different but no less real. If you sit back and do nothing, you run the risk of a major injury, which might be a stroke, a heart attack, diabetes, or a host of emotional issues such as anxiety and insomnia. So what can you do to protect yourself?

Taking care of your physical and mental health is your best defense. You can shift the odds in your favor with a few simple rules, such as getting a good night's sleep, exercising and reaching out to others when you need help. No person is an island, and we depend on each other for strength and comfort.

What have I missed from this construction scene?

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We're always reminded, especially in our younger years, of the importance of staying focused and not getting distracted. I write about this frequently in this blog, but sometimes I don't follow my own advice. Let me explain.

If the stress in your life is more than you can cope with, get help right away.

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A short while ago, I was invited to speak before a professional audience. As happens on occasion, one or two colleagues came up to the stage and asked if they could have my presentation on a USB flash drive. Of course I agreed. The procedure to do this is somewhat complicated and requires some focus on my part.

As I was trying to accommodate this request, another colleague came up to me and asked some very complicated questions. When my computer nearly melted down, I realized that I couldn't simultaneously complete the task and respond to questions. I then had to spend precious time dealing with the technical tsunami I'd created for myself.

Let me give you another example of why staying focused is so vital. A week or so ago, my wife and I had blocked out several hours on our calendars to pack and prepare for a trip. Despite that, we both accepted a number of other commitments for this time. We became distracted. We lost focus and energy and, as a result, we failed to follow some basic rules of travel, such as making sure we had our passports, confirming flight times, and so on. As you can imagine, our trip was punctuated by a number of misadventures.

These experiences served to remind me of the importance of protecting my time so that I can focus on the task at hand. Some lessons take repeating, I guess. Can anyone relate?

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An obscure article about a young baseball player caught my attention. It provided a golden teaching moment. Let me explain.

If the stress in your life is more than you can cope with, get help right away.

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Because of the astronomical salaries commanded by top professional athletes and because teams have a fixed budget, no coach or general manager can afford to mortgage the franchise by paying millions of dollars to a player who can't perform at a high level for many years.

The situation becomes even more complex because these million-dollar contracts are often guaranteed regardless of the player's performance or professional longevity. Once upon a time, a manager or a coach would sign one of these players based a gut feeling. Today, managers use laptops and spreadsheets to analyze every aspect of a player's strengths and weaknesses.

It's long been an accepted tenet in baseball that once a pitcher exceeds 100 pitches a game, his performance will decrease and his career will be in jeopardy. So the baseball community reacted with astonishment at the news that a high school pitcher had a 100-miles-per-hour fastball — an unheard of speed — and could comfortably throw 200 pitches a game on consecutive days.

Squadrons of scouts with radar guns and video cameras descended on his small community. The rumors were correct. The legend was real, and thus began an arms race of bidding for his services.

After incredible publicity and negotiations with lawyers, agents and representatives, the young man signed a lucrative multimillion-dollar contract. He entered his first game like a conquering hero. For the first half of the season, he lived up to his expectations — throwing a rocket-like fastball and easily exceeding 100 pitches a game. But then biology caught up with him. His speed decreased. His accuracy evaporated, and he was repeatedly injured. And then disaster struck — he tore a major ligament.

So what's the lesson here? Everyone has limits. If you exceed them, you must be prepared for the consequences. Sure you can burn the candle at both ends for a time, but sooner or later you'll pay the price. You only have so much mental and physical energy. If you don't pay attention to your well-being and you allow yourself to be whipsawed by the demands of others, you won't be able to go the distance.

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As I reflect on the past year of our survivorship blog, it seems notable that many of you have mentioned the positive presence of people in your lives during this time.

These are the friends and family who know and understand how to love, support and simply be with you. This might also include people you've met along the way during your experience as a patient.

Now, it might also include those who are supporting each other through this blog. It's so amazing to see the love and strength that you're giving each other.

It's sometimes difficult for others to know how to be with someone who's experiencing cancer. Cancer is personal. It threatens our mortality, our lives, and the people around us in so many ways.

At times, friends and family pull away, not knowing what to do. However, this is the time when you may need them the most. I would love to hear from you about this. What has been your experience? What do you need the most from others?

Honest feedback may help others understand what kind of presence is the most helpful to a person experiencing cancer. I want to thank all of you for your presence on this blog in the past year.

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Finding the resources and information you're looking for is a daunting task. Discovering good, sound and reliable sources can be even more difficult — especially on the Internet.

For those of you living with a past or present diagnosis of cancer, being well informed is one of your best defenses. Some of you have asked recently about finding research updates, the latest in treatment options and how to know what's best for you.

Here are some ideas on how to find the information and education resources that you're looking for:

Get personalized assistance — Go in person to your clinic or health care center and ask if they have a patient library or resource center. Most often the library or education center is staffed with a librarian and educators who can assist in your search for research updates, information and resources. Mayo Clinic Cancer Center in Rochester, Minn., has a Cancer Education Center located on the lobby level of the Gonda building that's open every day (Mon. - Fri.) and can assist with your personal information and educational needs. For more information call 507-266-9288.

Find reliable sources online — Here are a few ideas to help you get started.

Mayoclinic.com — search on the cancer topic you are researching and receive the latest evidence-based updates, see also the links at the bottom of each page for references related to the content.For information and education resources that you can download, go to the National Cancer Institute (NCI) Publications Locator (www.cancer.gov) or the American Cancer Society (www.cancer.org).For information about cancer clinical trials, see our Mayo Clinic site (go to the Resource tab on this page and link to cancer clinical trials) or the NCI site and search for the Clinical Trial Homepage.For excellent research updates see Mayo Clinic Cancer Center (www.cancercenter.mayo.edu), the American Institute for Cancer Research (www.aicr.org), the American Cancer Society (www.cancer.org), or the American Association of Cancer Research (www.aacr.org).

Subscribe to a cancer journal or newsletter — a few suggestions include:

Mayo Clinic "Living with Cancer" newsletter (link to subscribe is on this page)"Coping with Cancer" magazine and website (www.copingmag.com/cwc/index.php)"CURE (Cancer Updates, Research & Education)" (www.curetoday.com)"CR" magazine — from the American Association for Cancer Research (www.crmagazine.org)

Feel free to share other excellent resources that have helped you in your search for information as a cancer survivor.

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Guest blogger and breast cancer survivor MaryEllen Sheppard is our writer this week. She's graciously allowed others to share in her journey.

A video series about her experience, "MaryEllen's Journey — A 5-part breast cancer video series from Mayo Clinic," can be found on the Resources tab on this page. The following is her perspective:

"Living with cancer." I'm struggling with what to write because, fortunately, the phrase doesn't apply to me. My heart and prayers go out to you for whom the words do apply. However, I had cancer. I'm not living with it today. In my mind, there's a huge difference between the two.

Today, after successful surgery and treatment, I get to drop the "with cancer" part and just focus on the "living" part of the equation. Not only do I get to change the focus, I believe I must change it if I'm going to have the kind of future I expect for my family and myself.

Don't get me wrong, cancer's presence is evident. When I look at my chest I see the changes in breast contour and firmness resulting from the lumpectomy and radiation. I see reddened skin from an allergic reaction to surgical tape. The scars from surgery and the placement of a port, although better each day, still seem almost angry in comparison to my pale chest.

This visual reminds me of any number of brick walls marked with graffiti signifying which gangs have laid their claim. Only in my case the territory invaded was my chest and the words tagged and left behind read, "Cancer was here."

What is important, however, is while the evidence is indisputable that cancer claimed its territory in my body, because of the medical expertise of Mayo Clinic and the larger medical community, it didn't claim my life. Equally important, due to the compassion shown by so many, many people, cancer also failed to claim my joyful spirit.

I had cancer. However, like other major challenges I've faced, I'm choosing to learn from the experience and make changes based upon the lessons learned. I'm holding on dearly to the belief this is my life and cancer can't have any more of it. I'm surrounding myself with friends and family. I'm exercising and eating right. I'm doing my best to ensure there is no more territory ripe for the taking. In other words, I'm not living with cancer ... I'm living!

(As always, you're invited to share your comments. And you can find the video series, "MaryEllen's Journey — A 5-part breast cancer video series from Mayo Clinic," on the Resources tab above.)

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What is resilience? For you as a cancer survivor, it might be defined as the ability to recover, the strength to move forward, and the awareness of the needs of your own body.

Resilience is a strength that comes from within and is self-motivating. Research has shown that cancer survivors, when questioned, many times identify their own inner strength as one of the primary sources of strength as they experience and recover from a cancer diagnosis and treatment.

Many of you can identify with this concept, although it may be hard to put into words at first. Here are a few thoughts to consider as you reflect on your own resilience:

How do you bounce back from difficult situations? What are your coping mechanisms?How do you gain strength and courage to move forward? What motivates you?Are you able to ask for help when you need it? What is your support system?What inspires you and makes you feel whole as a person?

I have met so many survivors who have this amazing ability to survive and thrive despite the physical and emotional stress of cancer. Please share your thoughts on this topic. I would love to hear your opinion on what you feel is resilience and how this inner strength has helped you in your experience.

As a cancer survivor, you may be at risk for the occurrence of a second cancer. After treatment is completed it's great to have a break from all of the medical appointments. However, it's important to keep in mind prevention strategies and screening practices for the future.

As a cancer survivor, your risk for developing another cancer may be higher than the average person. This risk may be due to:

Chemotherapy drugs — Some may put you at risk for developing secondary leukemia. Radiation therapy may put you at risk for developing second cancers that are solid tumors. People at increased risk are those who have received high doses of radiation over a large area.Genetic mutations — Some people have inherited gene changes or mutations that increase the chances of getting a second cancer. If you feel that your family has a higher than average incidence of cancer, seek out a genetics specialist to review your family history and evaluate your risk.

What's important to keep in mind?

You may need more frequent or earlier screening than the recommended practice. Ask your health care provider what's recommended for you personally. Understand your risk for a second cancer. If you had treatment for cancer ask your cancer treatment team what your risk is for developing a second cancer. Be aware of changes in your body. Pay attention to new or unusual symptoms including: skin changes, swollen lymph nodes, unusual bleeding, pain, and excessive fatigue. Practice healthy habits for cancer prevention. Don't use tobacco, protect your skin from sun exposure, limit alcohol intake, incorporate exercise into your routine, and eat a healthy, low-fat diet (fruits, vegetables and whole grains).

Celebrate your life by remembering your risk and understanding what's best for your future. If you're not sure what you need, ask your cancer treatment team or primary care provider to help you plan for your future screening. Many of you have mentioned that you're dealing with a second cancer. Use this blog to share your experiences with each other.

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A while back, we had a discussion about grief and dealing with a terminal diagnosis. Many of you shared your perspectives on having a terminal diagnosis, the grieving process or the death of someone you love. It seems like another discussion on preparing for death might also be important.

Unfortunately, the word "cancer" can bring unwanted fear and anger — emotions that either you or those around you might experience. We all know that we will die some day. It's just that the exact circumstances (when, where and how) are unknown. However, rather than deal with this idea with fear, why not treat this as a time to think about living and dying with the idea of compassion and kindness for yourself and your family.

It's true that most people don't want to discuss dying, but if you're interested in finding some peace for yourself, you might consider a couple of these ideas:

Reflect on the positive aspects of your life; find strength in your deepest values.Keep in mind what is most important to you (in life and after you are gone).Write or tell stories of your fondest memories for your friends and family to reflect on now and later.Inquire early about hospice care. Getting hospice involved earlier rather than later can make such a difference. Hospice care has a holistic approach and can assist you and your family with the entire process of approaching your last days and months in a positive manner.Talk about, or write down what you want to happen after you are gone — this might include funeral planning, memorial ideas and any special requests related to the giving of meaningful personal items to others.

My wish for this discussion is to give you the freedom to reflect on the idea and talk with others about what you need.

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Mentor, navigator, advocate ... these are just a few of the people that you may have been touched by as a cancer survivor.

Most times, the people who fill these roles have faced cancer on a personal level as well. They've walked in your shoes and may have similar experiences to share. The art of caring, listening and supporting is so valuable.

Helping others make it through the experience of living with cancer is an incredible gift. They help you navigate your way through diagnosis, treatment and the time after treatment ends, which can be the hardest period.

People in these roles often want to give back by providing support and guidance to others who may be just at the beginning of their cancer experience. This is an empowering experience where the person helping oftentimes gets back as much as they give. For the person receiving the support, it's just so good to be with someone who knows exactly how they're feeling.

At Mayo Clinic Cancer Center, we are so fortunate to have American Cancer Society Navigators and volunteer survivors who work in the Cancer Education Center, Pink Ribbon Mentors who support breast cancer survivors, a strong group of men who organize the Prostate Cancer Support Group, as well as countless other advocates and community support.

Please share stories of how you've been touched by people in these supportive roles. Whether you were on the giving or receiving end, both are equally important!

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Last year, we had a blog discussion on "How cancer changes you" and so many of you wrote in to share your experiences. With this post, I want to delve deeper into the positive side. I realize it might be asking a lot to do this; however, while having cancer is a generally negative occurrence, some positive things may come from it.

I'll share a story of a woman I met who was diagnosed with breast cancer. After her initial treatment, she decided to reduce her work schedule and pursue her love for painting. She traveled to places she loved and created incredible watercolor paintings reflecting on the beauty of each place.

She stayed active in her work life, but was able to balance it with her dream of painting again. She told me she wouldn't have done this if it hadn't been for her cancer diagnosis. Previous to her diagnosis, she was extremely focused on her career and had put her love for painting on hold.

I'm sure this story isn't unique. Many of you have made positive changes in your life because of your cancer diagnosis. I've heard so many stories of love, courage and strength. At times, it's hard to be positive, as having cancer isn't exactly easy and the physical feelings of the body usually have a strong influence on the mind and outlook.

I would love to hear about your personal experiences. How did you transform the negative to positive? How did this experience change your life?

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In recent years, genetic testing to predict your cancer risk has become more available. As researchers learn more about how genes can predict your cancer risk, it's important to consider all the options.

If you're in a high-risk family, you may be considering genetic testing. The most common cancers that have a genetic component include breast, ovarian, prostate and colon cancers (along with many others as well).

Before you undergo genetic testing, gather as much information as you can about your family and medical history. Talk with your doctor or a genetic counselor about your personal and family medical history. This will help you better understand your risk. Discuss any questions or concerns you have about genetic testing. Also, talk about what your options will be, depending on the results of the test.

If a positive genetic test is discovered, you'll be able to talk with an expert about your specific risk. Some of the benefits of genetic testing include early interventions to decrease risk of actually developing cancer, such as:

More frequent screening tests (detecting cancer earlier with increased survival rate — colon cancer is a good example)Prevention strategies including positive lifestyle changes (such as diet and exercise)Informed decisions can be made for pro-active interventions (for example a decision to have prophylactic mastectomy or removal of ovaries for women with high risk to develop breast or ovarian cancer)

The field of studying genes for predicting cancer is evolving constantly. We are only at the beginning stages of understanding how genes predict our cancer risk and many other aspects of health.

Please share your thoughts on this topic and your personal experiences. blog index

Lymphedema refers to swelling that occurs in one of your arms or legs that is caused by a blockage in your normal flow of the lymphatic system, an important part of your immune and circulatory systems. The blockage prevents lymph fluid from draining normally, therefore as the fluid builds up, the swelling continues.

In people who have been treated for cancer, lymphedema may occur as the result of surgery or radiation during the treatment for cancer of the breast, ovaries, prostate, as well as sarcoma, lymphoma and melanoma in both men and women.

Lymphedema symptoms include:

Swelling of part of your arm or leg or your entire arm or leg, including your fingers or toesA feeling of heaviness or tightness in your arm or legRestricted range of motion in your arm or legAching or pain in your arm or legRecurring infections in your affected limbHardening and thickening of the skin on your affected arm or leg

Because of improvements in radiation and surgical techniques (such as the use of sentinel node biopsy), lymphedema is less common today. However, lymphedema, when it does occur, requires careful attention and can be difficult to manage on a daily basis.

There's no cure for lymphedema. Treatment focuses on reducing the swelling and controlling the pain. Lymphedema treatments include:

Exercises. Light exercises that require you to move your affected arm or leg may encourage movement of the lymph fluid out of your limb. Ask your doctor for a visit with a lymphedema therapist who can recommend exercises and strategies that are best for you.Wrapping your arm or leg. Special compression sleeves and bandages to reduce swelling may be part of your recommended treatment.Massage. A special massage technique called manual lymph drainage encourages the flow of lymph fluid out of your arm or leg. Manual lymph drainage involves special hand strokes on your affected limb to gently move lymph fluid to healthy lymph nodes, where it can drain. Pneumatic compression. If you receive pneumatic compression, you'll wear a sleeve over your affected arm or leg. The sleeve is connected to a pump that intermittently inflates the sleeve, putting pressure on your limb. The inflated sleeve gently moves lymph fluid away from your fingers or toes, reducing the swelling in your arm or leg.

If you are living with lymphedema, it is important to take special precautions:

Avoid vaccinations, injections, blood pressure monitoring, blood drawing, and intravenous administration in the arm affected.Do not wear tight-fitting clothing or jewelry.Be aware of exposure to extreme temperatures, such as sunburns, hot baths, and saunas.Watch for early signs of infection such as redness, swelling, increased warmth, tenderness, or fever.

If you have lymphedema and are struggling to manage the symptoms, request an appointment with your health care team to discuss your plan. Specifically ask for a visit with a lymphedema specialist so that you can learn as much as possible about potential management strategies.

During your visit, request the documentation needed to assist you with insurance coverage of the treatment recommended. Many times, physical and massage therapy will require a letter of medical necessity for your medical insurance to cover the costs.

Get support from others who are also experiencing lymphedema. Breast cancer survivors have formed dragon boat teams throughout the country to support each other through a successful training and exercise program. Also, visit the National Lymphedema Network website to find support groups in your area. Share your experiences and ideas with each other through this blog.

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As I look ahead to 2011, I'd love to get your feedback on our newsletter and blog topics.

We had a great year of discussions in 2010. The Living with cancer newsletter and blog are growing in popularity because of all of you.

I appreciate your comments, discussions and support. At Mayo Clinic, we strive to be dynamic, responding to research, news and updates in the cancer world as it unfolds.

Let's begin 2011 with a discussion on what we can do to improve your experience online.

What topics would you like to see in the newsletter and blog? What improvements would help you to better connect with each other? Also, let us know what we're doing well so we can keep meeting your needs in the best way possible.

Thank you for your readership in 2010. I look forward to hearing your ideas and receiving your feedback.

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Relationships and the give and take that is part of the process of being in a relationship are present in our everyday lives.

As I reflect on what's written by so many of you, this seems to be a key component to thriving as a survivor. Your personal quality of life is directly affected by the quality of your relationships with others.

This includes your family, your partner or spouse, your work colleagues, your friends, and also your health care team. This connection of one to another is how each day moves forward.

A few of the key components to a relationship are communication, trust, flexibility, honesty and time. If you're not getting what you need from a relationship, it might be time to act on it. Here are some ideas for getting the most from your relationships:

Communicate your needs, wishes and desires — be specific.Be honest about what to expect from others — this includes everyone from your family to your health care provider. Give yourself time to heal and adapt to the changes that you may have in your life.Keep in touch — send a note or call a friend who you treasure and haven't seen for a while. Make a date to reconnect.Be open to new relationships — surround yourself with positive people.Give back when you can — take time to thank those people in your life who have made a difference. A simple phrase such as "thank you for being part of what's good in my life" can bring a smile to them and help them realize how much the relationship means to you.blog index

Let's explore the concept of pain together. You can experience different types of pain, including pain from the cancer tumor or location of the tumor, or from side effects of treatment (radiation, surgery, and/or chemotherapy).

From my perspective, many people are reluctant to talk about pain with their cancer doctor either because they think it is something they must live with, or they do not want to "bother their doctor" with the question of pain relief.

Pain relief is extremely important and can directly affect your quality of life, ability to move forward in your recovery, as well as your emotional and psychological well-being.  Talk to your health care team about your pain.  Most cancer centers will have a pain clinic where you can meet with a pain specialist to address your individual concerns.

Investigate other ways to balance your medical treatment plan for pain relief by exploring alternative therapies including:

AcupunctureAromatherapyBiofeedbackHypnosisMeditationMassageMusic therapy

Much progress is being made related to pain relief for people with cancer, however, more remains to be accomplished.  Please share your perspectives on this topic together.

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A few weeks ago, I asked for your feedback and ideas for topics and discussions for 2011. Thank you so much for your comments, ideas and suggestions. It's clear some of you aren't finding what you're looking for. Here are a few ideas on how to find Mayo Clinic's information on cancer treatments, research and support.

At the moment, you're on the Expert Blog of the Cancer guide at mayoclinic.com/health-information/. If you look all the way to the left (above my picture) you will see the tab called Basics. That's where you'll find more about cancer in general — everything from symptoms to treatment and prevention.

Next, you'll see a tab called In-Depth, where you'll find a variety of information (I highly recommend you check it out) from the latest on treatment and drugs, alternative medicine, coping and support. The Multimedia tab is next. This one is great for people who like visuals — you'll find images, videos and slide shows related to the cancer. Expert Answers is the next tab. You'll find great snippets of information from Mayo Clinic cancer experts written in a question and answer style.

To the right of that is the Expert Blog tab. Then, next to the Expert Blog tab is a tab called Resources. You'll find many helpful links to other great resources within Mayo Clinic and external links to important support resources. The Resources tab is where you'll find the link to our Cancer Clinical Trials site to find out more about treatment trials and clinical research opportunities at Mayo Clinic. The last tab called What's New features the newest cancer information.

I hope you'll find this information helpful as you navigate on our site. Depending on how you found the blog, you may or may not be that familiar with the site. We're here to help in your survivorship journey. Feel free to send me any comments or suggestions that you might have.

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If you're someone who has just been diagnosed with cancer, it is overwhelming to deal with all of the information and decisions needed to move forward in your cancer care. It's important to learn all you can and ask questions along the way so that you have confidence in your treatment plan and the team leading you through treatment. Here are a few questions to consider as you start to make decisions:

Is this the person (doctor, nurse practitioner, etc.) you want to lead you through your treatment experience? Do you have confidence in them? Are you comfortable with them? Do you feel that they're able to listen and respond to your concerns? If the answer is no to any of these questions, it's OK to ask for a different provider.Do you have enough information to make a decision about your treatment? If not, what is needed? Take time to understand all aspects of your treatment options.Does the treatment facility specialize in your cancer type? Ask about their experience with your cancer type, success rates and resources.Should you ask for a second opinion? Remember that it's OK to request this. What are the risks involved with treatment? Ask about short- and long-term side effects.What about when treatment is over? Ask about the long-term plan for care after treatment ends.Do you have a support person (or persons) to be with you along the way? This might be a family member or friend who can help you absorb and reflect information and decisions. They can also be there when you need emotional and physical support. If you don't have someone, ask about resources that are available to help you, such as mentors, coaches, navigators, social workers and educators.

One of the most important things is confidence in your treatment team. Take time to get your questions answered so that you can make informed decisions. I know that many of you can add to this list, as you learn so much from each other. Share your ideas and suggestions as you coach each other through this experience.

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This is a heavy topic to discuss; however, many of you have mentioned that you're dealing with a terminal diagnosis.

Grief is a strong, overwhelming emotion, regardless of whether your sadness comes from the loss of a loved one or from a terminal diagnosis that you or someone you love has received. You might find that you feel numb and disconnected from your daily life, unable to carry on with your regular routine as you're dealing with the emotions and sadness of grief.

Grief is the natural reaction to loss. Grief is both a universal and a personal experience. Individual experiences of grief vary and are influenced by the nature of the loss. It's important to remember while you're grieving that you can't control the process and to prepare for varying stages of grief. Some emotions you may experience during the grieving process include:

Denial AngerBargainingDepressionAcceptance

Grieving doesn't always follow the stages above, but you may experience many of these feelings as you deal with the reality of a terminal diagnosis. A host of emotions are involved and normal. You might experience a sense of shock, sadness, guilt and fear along the way. Talking with others is sometimes helpful as you try to recover from the shock and adjust to a diagnosis of a terminal illness.

I want to have an open discussion about grief through this blog so that you might help each other with some of the feelings and emotions. It's not an easy discussion to have, so I admire your willingness to share.

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The financial burden for cancer survivors is significant. In a recent study, more than 30 percent of people living with cancer said they had practical concerns regarding financial issues. On top of monthly or yearly insurance premiums, extra costs such as co-pays, medication (chemotherapy or treatment) expenses, travel costs and lost wages are all part of the equation as you deal with a cancer diagnosis, treatment and survivorship.

Some practical ideas that may help as you navigate your way through these issues include:

Talk with your health care team on an ongoing basis about treatment costs. If they recommend a new medication or prescription — ask about your out-of-pocket costs. Many times, your cancer treatment center's business office and pharmacy can give you an estimate of costs before hand.Meet with a social worker to review potential financial resources available to you. This might include charity care, prescription assistance programs, gas cards, low cost (or no cost lodging) and other resources.Call the American Cancer Society (1-800-227-2345) to connect with resources that are available to you as a cancer survivor. If you are unable to work because of your cancer diagnosis; talk with your employer to plan for medical leave, or call the Social Security office (1-800-772-1213) to discuss your options for disability benefits.

Feel free to share ideas, pearls of wisdom and any resources that you have found helpful.

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Relaxation therapies may help alleviate certain symptoms of cancer, relieve side effects of treatment, and improve your sense of well-being.

Many relaxation methods, such as massage therapy, meditation and guided imagery may be helpful in managing stress and anxiety. In addition, research studies show that relaxation techniques can lower blood pressure, reduce pain, and ease some side effects of chemotherapy.

Having cancer is stressful, so it may not be possible to eliminate all sources of stress. But you should consider the sources of stress that you can reduce. For example, ask for help with household chores, social responsibilities or work demands. Seek out effective strategies for coping with stress or simplify your life by saying "no" to the extra demands as much as possible.

Common relaxation techniques include:

YogaTai chiListening to musicExerciseHypnosisGuided imageryMassage therapy

Relaxation techniques involve refocusing your attention from the stress to something calming.

For me, it's taking a daily hike and being mindful of the changes in nature around me. It might be the sound of the birds chirping, new leaves on the trees, the beauty of the clouds against the blue sky, or a neighbor, cat or dog that welcomes me along the way.

I return refreshed and ready to take on the rest of the day. Choose a relaxation technique that works best for you and incorporate it into your daily routine. Share with others through this blog what has worked for you.

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Music has the ability to change moods, soothe nerves and energize your life. Much research has been done on the physical and emotional effects of music. Some of the benefits that have been noted in research include:

Improves communicationEnhances memoryReduces pain sensationCounteracts depressionPromotes activity (i.e. dancing, exercise)Encourages feelings of relaxationCalms and sedates (promotes sleep)

Explore ways to incorporate music into your life. For energizing ideas, think of ways to use music to promote movement. I have a friend who takes a break every day with music. She turns on the music and just dances for an hour! Dance to the music as much or as little as you can; just let your body move to the rhythm of the music.

For relaxation ideas, find your favorite songs and take time to meditate. Let the music transport you to another place and time. Allow your mind to drift away to positive thoughts and memories. Close your eyes and take in the music around you; it will make you smile inside and out!

I would love to hear from others who use music in their lives. Share ideas and thoughts, and even music titles for others to get inspired.

A few weeks ago, I wrote about terminal cancer and grief. Let's continue the discussion by talking about the idea of a bucket list. The term is based on the 2007 film "The Bucket List," featuring Jack Nicholson and Morgan Freeman as two terminally ill men who went off on an adventure to fulfill a list of things they wanted to do before they died.

It's important that we all create a list of the things we'd like to either experience or accomplish in our lives (terminal diagnosis or not). These are the things you've always wanted to do, but for some reason never did. It's a life experience list.

Create your own bucket list and make plans to fulfill them one at a time. Begin with simple items that might be fairly easy to accomplish, and move on to others that might take some time and support to accomplish. It might help to share your list with a close family member or friend. Talking about what you want to accomplish can help you begin to fulfill your dreams and give you a sense of pure joy and happiness.

As a cancer survivor, you may have changed your life priorities, goals and important items on a life experience list such as this. Please share your ideas about a bucket list. If you don't have a bucket list yet, this is your invitation to start one.

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Summer brings out barbecue grills—and bacteria, which multiply in food faster in warm weather and can cause foodborne illness (also known as food poisoning). Following a few simple guidelines can prevent an unpleasant experience.

Wash your hands

Wash hands with soap and water for at least 20 seconds before and after handling food. If you're eating where there’s no source of clean water, bring water, soap, and paper towels or have disposable wipes/hand sanitizer available.

Marinate food in the refrigerator

Don’t marinate on the counter—marinate in the refrigerator. If you want to use marinade as a sauce on cooked food, save a separate portion in the refrigerator. Do not reuse marinade that contacted raw meat, poultry, or seafood on cooked food unless you bring it to a boil first.

Keep raw food separate

Keep raw meat, poultry, and seafood in a separate cooler or securely wrapped at the bottom of a cooler so their juices won’t contaminate already prepared foods or raw produce. Don't use a plate or utensils that previously held raw meat, poultry, or seafood for anything else unless you wash them first in hot, soapy water. Have a clean platter and utensils ready at grill-side for serving.

Cook food thoroughly

Use a food thermometer to make sure food is cooked thoroughly to destroy harmful bacteria. Refer to the Safe Minimum Temperatures chart for safe internal temperatures for foods. Partial precooking in the microwave oven or on the stove is a good way to reduce grilling time—just make sure the food goes immediately on the preheated grill to finish cooking.

Keep hot food hot and cold food cold

Keep hot food at 140°F or above until served. Keep cooked meats hot by setting them to the side of the grill, or wrap well and place in an insulated container.

Keep cold food at 40°F or below until served. Keep cold perishable food in a cooler until serving time. Keep coolers out of direct sun and avoid opening the lid often.

Cold foods can be placed directly on ice or in a shallow container set in a pan of ice. Drain off water as ice melts and replace ice frequently.

Don’t let hot or cold perishables sit out for longer than two hours, or one hour if the outdoor temperature is above 90°F. When reheating fully cooked meats, grill to 165°F or until steaming hot.

Transport food in the passenger compartment of the car where it’s cooler—not in the trunk.

Put these items on your list

These non-food items are indispensable for a safe barbecue.

food thermometerseveral coolers: one for beverages (which will be opened frequently), one for raw meats, poultry, and seafood, and another for cooked foods and raw produceice or frozen gel packs for coolersjug of water, soap, and paper towels for washing handsenough plates and utensils to keep raw and cooked foods separatefoil or other wrap for leftovers

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

 

A U.S. Customs and Border Protection official inspects an imported shipment.

 

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Six months after President Obama signed the landmark FDA Food Safety Modernization Act (FSMA) into law, the Food and Drug Administration continues to move forward in its efforts to protect the nation’s food supply.

According to the Centers for Disease Control and Prevention, 48 million Americans get sick each year from foodborne diseases each year and 3,000 die. A recent outbreak of a virulent strain of E.coli in Europe, which killed dozens of people and made thousands sick, has raised new concerns about food safety here.

But the food safety act gave FDA a mandate to implement a system that is based on science and addresses food safety hazards from farm to table. The agency has already strengthened a number of protections, including making it easier for consumers to learn about recalled foods and providing safety guidelines for commercial fisherman and fish processors.

After the legislation became law, FDA had 180 days—on or before July 3—to meet other specific goals. And, in accordance with that deadline, the agency has taken two new actions, one to prevent the smuggling of food into this country, and another to make sure that all new ingredients in dietary supplements are safe for consumers.

The law “requires the agency to build a new food safety system,” says Michael R. Taylor, FDA’s deputy commissioner for foods. “This new system will better leverage the resources of federal agencies and it will make industry a major partner in safeguarding the health of U.S. consumers.”

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The new anti-smuggling strategy was developed by FDA, the Department of Health and Human Services (HHS) and the Department of Homeland Security (DHS). Within DHS, FDA is working with Customs and Border Protection (CBP) and Immigration and Customs Enforcement (ICE).

The goal is to better identify and prevent the entry of smuggled foods that could be dangerous to both national security and consumer safety. Food may be smuggled for many reasons, including for economic gain, to evade import taxes, evade routine inspection that could raise safety concerns, or for more dangerous reasons, including plots to intentionally harm the American public. 

FDA will be working closely with CBP to identify import shipments that could conceal undeclared foods.

The law defines smuggled food as “any food that a person introduces into the United States through fraudulent means or with the intent to defraud or mislead.”  And while this could be interpreted to apply to a food item concealed in someone’s luggage, the agencies will be focusing on imported foods that pose a significant public health risk.

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FDA has a history of taking legal action against supplement makers who include hidden or deceptively labeled ingredients in their products. These could potentially be dangerous to consumers, especially those using medications or with a health condition.

This time the agency is issuing a draft of a guidance document for the dietary supplements industry stipulating that manufacturers must notify the agency in advance when adding a new ingredient with an unknown safety profile to their products. The manufacturers must also provide evidence that the ingredient is safe for consumers.

If the notice from a supplement firm is deemed inadequate because the new ingredient is an anabolic steroid or a material with the same chemical qualities, FDA is required to alert the Drug Enforcement Administration.

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In addition to the actions listed above, FDA now has the authority to prevent the distribution of unsafe food by suspending the registration of the processing facility. Food producing firms must be registered with FDA to market their products in the U.S.

The registration could be suspended if the food processor not only fails to produce safe foods, but also takes no measures to keep those foods from reaching consumers. In addition to preventing their distribution, the processor of unsafe foods would be expected to investigate what went wrong and take steps to prevent a recurrence. If this is not done, FDA will step in.

One of the food-safety law’s major provisions is a requirement that food facilities have a written preventive controls plan that spells out potential safety problems and the steps that would be taken to prevent or minimize the likelihood of these hazards occurring.

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Also now in effect is a rule, issued on May 4, that allows FDA to detain for up to 30 days food products it believes may be adulterated or misbranded. Such foods would be kept out of the marketplace until the agency determines whether there is a need for further enforcement actions, such as seizure or an injunction to prevent the suspect products from being distributed.

The food safety law set another goal that was to be met by July 3: the issuance of the Fish and Fishery Products Hazards and Control Guidance, This document, popularly known as The Hazards Guide, was issued in April, well ahead of the deadline. The guide provides commercial fisherman and processors the latest scientific information on contaminants and the controls needed to eliminate them.

FDA delivered the first tangible product of the historic food safety reform legislation on April 4: a new web-based search engine that makes it easier and quicker to learn about product recalls. At the same time, the agency redesigned its web page dedicated to the food safety act: www.fda.gov/FSMA.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

 

Federal regulators unveiled nine graphic warnings that must be on cigarette packaging and advertisements by September 2012. The warning above shows healthy lungs (left) and the diseased lungs of a smoker. View the Warning Labels on Flickr.

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Consumers are getting a glimpse of warnings images that will be alternating on all cigarette packages and advertisements within 15 months—an effort by health officials to discourage smoking by bringing Americans face to face with tobacco-related disease.

The Food and Drug Administration unveiled the nine, color images—including some of  bodies ravaged by disease—at a news conference. The images, which are paired with text health warnings, are required under the 2009 Family Smoking Prevention and Tobacco Control Act. They must appear on every cigarette pack, carton, and advertisement by September 2012.

“President Obama is committed to protecting our nation’s children and the American people from the dangers of tobacco use. These labels are frank, honest and powerful depictions of the health risks of smoking and they will help encourage smokers to quit, and prevent children from smoking,” said Health and Human Services Secretary Kathleen Sebelius.

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In November, FDA officials posted 36 images on the Internet and gave the public 90 days to comment. The agency received more than 1,700 comments from the public, retailers, health professionals, advocacy groups, the tobacco industry, state and local public health agencies, and others.

Regulators used the comments, scientific literature, and the results of an 18,000-person study to narrow the images to nine. Each of the images—a mix of illustrations and photos depicting the negative health consequences of smoking—will be paired with one of these nine printed warnings:

WARNING: Cigarettes are addictive—with an image of a man smoking through a hole in his throat WARNING: Tobacco smoke can harm your children—with an image of a parent holding a baby as smoke drifts towards themWARNING: Cigarettes cause fatal lung disease—with an image of a disease-riddled lung and a healthy lung WARNING: Cigarettes cause cancer—with an image of an open sore and stained teeth on the lips and mouth of a smoker with mouth cancerWARNING: Cigarettes cause strokes and heart disease—with an image of a man who needs an oxygen mask to breatheWARNING: Smoking during pregnancy can harm your baby—with an illustration of a crying newborn in an incubator and hooked-up to a monitorWARNING: Smoking can kill you—with the image of a dead man with a surgery-scarred chest  WARNING: Tobacco smoke causes fatal lung disease in nonsmokers—with an image of a grieving family memberWARNING: Quitting smoking now greatly reduces serious risks to your health—with an image of a man wearing an “I Quit” T-shirt

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FDA Commissioner Margaret A. Hamburg, M.D., says she’s hopeful the graphic images will give smokers the incentive to quit and prevent potential smokers from ever starting. In fact, the phone number for the smoking cessation hotline—1-800-QUIT-NOW—will accompany each warning.

“The Tobacco Control Act requires FDA to provide current and potential smokers with clear and truthful information about the risks of smoking—these warnings do that,” she says. 

The bold health warnings will cover the top 50 percent of the front and rear panels of all cigarette packages and at least 20 percent of each advertisement. They are expected to decrease the number of smokers, which will save lives and increase life expectancy.

For more information, visit www.fda.gov/cigarettewarnings.

The Centers for Disease Control and Prevention says tobacco use is the leading cause of premature and preventable death in the United States, responsible for 443,000 deaths each year. Tobacco addiction costs the U.S. economy nearly $200 billion every year in medical costs and lost productivity.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

June 21, 2011

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Want to know how a medication might affect your breast milk? Got a question about a disability, aging, mental health?

There’s an app for all that—and a whole lot more.

The variety and availability of smartphone applications—or apps—have exploded in recent years as multi-tasking consumers increasingly use their phones to keep up with the latest on news, finance, and health. Apple says its iPhone App Store has more than 350,000 apps, and Android, BlackBerry, Windows, and other smartphones account for tens of thousands more. With so many apps on the market, it’s no wonder the number of health care related apps has also spiraled.

The Food and Drug Administration (FDA) is now proposing guidelines that outline the small number of mobile apps the agency plans to oversee—medical apps that could present a risk to patients if the apps don’t work as intended.  The proposed guidelines were posted on the Federal Register website Thursday.

Consumers may weigh-in on the guidelines during a public comment period that ends Oct. 19.

For more information, visit FDA's Mobile Medical Apps page.

FDA policy advisor Bakul Patel says some of the new mobile apps are designed to help consumers manage their own health and wellness—like the National Institutes of Health’s LactMed app, which gives nursing mothers information about the effects of medicines on breast milk and nursing infants.

Other apps are aimed at helping health care providers improve and facilitate patient care—like the Radiation Emergency Medical Management (REMM) app, which gives health care providers guidance on diagnosing and treating radiation injuries. There are even apps to aid diagnosis of rashes and heart irregularities.

FDA has already cleared a handful of mobile medical apps used by health care professionals, such as a smartphone-based ultrasound and an application for iPhones and iPads that allows doctors to view medical images and X-rays. 

There's an app for that!

“There are advantages to using medical apps, but consumers and health care professionals should have a balanced awareness of the benefits and risks,” Patel says.

Apps can give consumers valuable health information in seconds and are opening innovative ways for technology to improve health care, Patel says. However, the small group of mobile medical apps FDA proposes to oversee present a potential risk—these apps may impact how a currently regulated medical device (such as an ultrasound) performs, he adds.

FDA is proposing to oversee mobile medical apps that: 

Are used as an accessory to an FDA-regulated medical device. For example, an app could enable a health care professional to view medical images on an iPad and make a diagnosis;Transform a mobile platform into a regulated medical device. For example, an app that turns a smartphone into an electrocardiography, or ECG, machine to detect abnormal heart rhythms or determine if a patient is experiencing a heart attack.

If you want to provide input on FDA’s proposal, you can submit your comment online at http://www.regulations.gov/ or in writing to: Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD  20852.

“We want to hear from as many consumers, advocacy groups, health care professionals, and software creators and distributors as possible to help us finalize the proposed guidelines,” Patel says.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.