Cancer Patients’ Guide To Christmas When You Have Children

Christmas is an incredibly tiring time, with events, family gatherings and activities constantly taking place throughout advent. 

But some parents’ festive plans may have been thrown a curveball with an oncology diagnosis or the start of cancer treatment, and they are worried about how they will cope with the hectic season while feeling unwell. 

Whether they are undergoing chemotherapy, radiotherapy or surgery, or are suffering from the cancer itself, they will not be physically or emotionally able to deal with the multitude of family festivities at this time of the year. 

However, this is not to say they can’t enjoy Christmas at all, as they just need to work out how they can get the most out of the festive period with their children even if they are not feeling their best. 

 

Manage expectations

Your original Christmas plans might not be able to go ahead, so it is important you and your loved ones decide how this year’s holiday will look like for you all. 

Being mentally prepared for this Christmas to look different is half the battle, but you will learn there are still some festive activities you can take part in even if they were not the ones you had planned. 

As well as managing your expectations, it is important to do the same with your family, especially children. Tell them what symptoms you are likely to be dealing with, from sickness to fatigue, loss of appetite to your hair falling out. 

If you explain to them now that you will not be able to go to the pantomime, Christmas grottoes and school fairs, but will find other ways to celebrate, they will have time to accept the news.

 

Think of alternative activities

Instead of late night shopping and New Year’s Eve parties, you will need to rest over the festive period. 

So why not snuggle down with loved ones to watch Christmas films? You could get your children wrapping the gifts or putting up the decorations as you watch some of your favourite festive movies.

Other alternative activities that, hopefully, won’t tire you out too much include reading some festive stories together, such as The Night Before Christmas; watching your little ones bake some Christmas cookies; or going for a wintry walk for some daily exercise. 

It is important for recovery to get moving every day, so going for a walk could become your daily family outing, so long as you listen to your body and don’t push yourself too much. 

 

Call in help

Cancelling Christmas entirely is not an option when you have children, but doing all the Santa jobs like shopping, wrapping, and cooking would be too demanding on anyone with cancer or going through treatment. 

That is why it is essential to get help from loved ones. Ask them to decorate your house, buy or wrap the gifts, make the dinner, or even do some cleaning. 

Maybe they could take the kids for a Christmassy day out so you have a chance to rest properly, or they could have them for a sleepover. 

Do not think twice about asking parents or friends for assistance, as even normal daily tasks, such as cooking, will feel like a struggle with the challenging symptoms you may be experiencing. 

 

Eat what you can

Cancer treatment can have a huge impact on appetite, thanks to nausea, vomiting, diarrhoea and constipation being common side effects. 

This means the idea of preparing, cooking and eating a big roast dinner with all the trimmings may make your stomach flip. 

So the best thing to do is keep it as simple as possible and only eat what you can. Talk to your kids about whether they really want a big traditional dinner, and if they do, try to get someone to help prepare it for the family. 

You can pick at parts of the meal you can face that day or just stick with small snacks, such as crackers, if you are feeling really unwell. 

However, you may find they are just as happy with something like sausages and chips, which would be a lot gentler on your stomach and much easier and quicker to prepare. This will give you all more time to open presents and watch Christmas TV. 

If you are feeling really sick over the period, your doctor can prescribe you anti-nausea tablets, which will help you get through those more difficult days. 

You might find you are able to eat or do more than you anticipated over the break, but do not expect too much of yourself, as you will only be disappointed. 

The most important things are to get the rest you need and enjoy the moments with your family when you are feeling better, without the pressure of having to make it a perfect Christmas.

All About The UK’s Largest Prostate Cancer Screening Trial

The future of men’s health in the UK is potentially set to change thanks to the announcement of a huge prostate cancer screening trial that could have major implications for oncology diagnosis and treatment in the future if it goes as well as existing breast cancer screening programmes.

The TRANSFORM clinical trial, set up by both the UK government and charity Prostate Cancer UK, is the most ambitious clinical screening trial in at least two decades and could potentially save countless lives by diagnosing men and ensuring they receive treatment sooner.

Depending on its outcomes, it could potentially transform cancer care for men and men’s health in general in the UK, much in the same way the NHS Breast Screening Programme has done for women.

To understand why, it is also important to understand the TRANSFORM trial, and what it is looking for in an effective, consistent, screening method for the most common type of cancer in men.

 

What Is TRANSFORM?

Announced on International Men’s Day, 19th November 2023, the TRANSFORM trial aims to rectify one of the biggest and most devastating diagnosis and care gaps in oncology, one that potentially contributed to 12,000 people losing their lives.

The trial, which will most likely begin at some point in the Autumn of 2024, will test a range of screening methods that have the potential to diagnose prostate cancer consistently, accurately and quickly.

The primary method of interest is MRI scans, which whilst far from a new technology for diagnosing cancer, have not been used at scale in a screening programme.

The focus is on reducing inequality and ensuring that life-saving diagnoses are discovered early on. Whilst the trial will have a relatively broad scope for recruitment of men between 50 and 75 years of age, there is also a target that a tenth of the men in the trial are black men between 45 and 75.

Whilst there are, as of its announcement, a lot of questions that still need to be resolved regarding start dates, number of trial subjects, which screening methods will be used exactly and the research centres involved in the process, there are some aspects that have been confirmed.

The budget has been set at £42m, £16m of which is set to come from the government itself. £1.5m has been earmarked from a partnership with the long-running men’s health charity drive Movember, and the rest will be generated by Prostate Cancer UK themselves.

It will also take advantage of the existing diagnostic ecosystem, including hospitals, oncology clinics and community diagnostic centres. They would provide a wide range of tests, which a successful screening regimen would perfectly fit into.

 

Why Does This Matter?

Currently, whilst prostate cancer is the most common form of cancer amongst men, there is currently no national screening programme to detect it.

Part of the problem is that prostate cancer does not often have clear symptoms except at an advanced stage, and the current tests used to detect it are not necessarily universal.

The primary early-stage test used for prostate cancer is the prostate-specific antigen test (PSA), which whilst available on request, needs other tests to be used in combination with it in order to be entirely effective.

It can only detect the appearance of biomarkers typically associated with prostate cancer, cannot detect the severity of a case, and can sometimes miss cancers or lead to false positives.

A better approach is required for a widespread screening programme in order to avoid missing anyone or causing unnecessary distress through a false positive.

After all, whilst progression and stages of cancer can vary by type and indeed on an individual basis, the fairly universal rule is that the earlier a cancer is spotted, the easier it is to treat as there are far more options for treatment available and far more time for those treatments to be effective.

A widespread screening programme, as has been proven with breast cancer, is the best way to ensure that men are effectively diagnosed as early as possible to avoid more complex and intensive treatments being required, or the worst-case scenario that it is no longer curable.

On top of the benefits specific to prostate cancer, the development of TRANSFORM coincides with a number of government men’s health initiatives designed to help raise awareness of not only prostate cancer but other men’s health issues.

The main initiative in this part of the work is a comprehensive series of updates to the NHS website, focusing on improvements to pages that are primarily used by men and helping to signpost and clarify the support available for certain conditions, including both prostate and testicular cancer.

As well as this, the government established the first task and finish group dedicated to men’s health, featuring campaigners, academics and behavioural scientists.

They aim to ensure that men engage with their health and have access to services that can help prevent or provide early diagnosis of potential issues, including takeup of the NHS Health Check and future screening programmes, as well as access to a GP.

Finally, they are also recruiting for a Men’s Health Ambassador, a public-facing role for people with expertise in men’s health who would take responsibility for boosting awareness of conditions, needs and fears commonly held by men.

The primary aim is to open conversations, smash stigmas and debunk a lot of the myths and taboos that often surround men’s health topics, which in turn will help to encourage men to check themselves and take a proactive approach towards their health.

The biggest part of this work, by far, is the contribution towards TRANSFORM, and the greater the resources put towards this trial, the better the potential outcomes, not just for the ultimate report, but the future of cancer detection.

After decades of attempts and a huge body of research, 2024 could be the year that sees the first steps towards making prostate cancer more visible, more easily detected and more easily treated than ever before, and giving access to high-quality diagnosis and medical treatment to as many men in the country as possible.

Pregnancy And Having Cancer – Everything You Need To Know

As soon as most women find out they are pregnant, they want to protect their little baby as much as possible. So to discover they also have cancer will feel even more devastating, as the happiest time of their lives has now become the most challenging. 

There are bound to be tons of questions pregnant women who have been diagnosed with cancer want answers to, so read on to find out what cancer means for the baby and what treatments options are still available. 

Will cancer affect the unborn child?

The first thing expectant mothers will want to know is whether the cancer will spread to the baby. 

It is, in fact, very rare for the cancer to reach the placenta and, therefore, be passed on to the foetus along with the oxygen and nutrients carried in the blood. 

To ensure the health of the baby, there are likely to be more ultrasound scans during the pregnancy. After the baby is born, doctors might investigate the placenta to check whether there were any cancer cells inside that could have spread to the child. 

What cancers are typically diagnosed during pregnancy?

Women can develop any type of cancer during pregnancy, but the most common are breast, gestational trophoblastic disease, cervical cancer, Hodgkin lymphoma, melanoma, non-Hodgkin lymphoma, thyroid cancer, and leukaemia. 

It can be harder to detect cancer in a pregnant woman, as their body is already undergoing a lot of alterations, many of which are similar to cancer symptoms. 

For instance, hormonal changes can cause tender, lumpy and bigger breasts; haemorrhoids in pregnancy can lead to rectal bleeding, which could, in fact, be colon or rectal cancer; and pregnancy fatigue could disguise signs of leukemias and lymphomas. 

What’s more, it can be harder to feel for any ovarian tumours as the foetus is growing. 

As a result, cancers might not be discovered until later on, giving it time to spread more in the body. 

On the other hand, sometimes being pregnant could help with the discovery of tumours. For instance, ultrasounds to check on the baby could show ovarian cancer, while a smear test would show abnormal cervical cells. 

Anyone who is concerned they might have cancer while pregnant should see a doctor, as there are some safe tests that can be done to determine whether there is a malignant tumour or not. 

Bone scans, CT scans and PET scans might have to be avoided so the baby is not exposed to radiation, but there are other checks that can still be carried out, including mammograms, ultrasounds, chest x-rays, and MRIs.  

What happens after you receive a diagnosis?

After being given a cancer diagnosis while pregnant, you will still be under the care of the midwife and obstetrician to ensure the pregnancy goes well and the baby remains safe and healthy. 

This means all the usual checks and scans will take place, while they might fit in more appointments to reassure you about the baby’s wellbeing. 

If the cancer is discovered at the beginning of the pregnancy, depending on the stage and spread of the illness, the oncologist might advise to terminate the pregnancy so you can begin aggressive treatment. 

However, in women who are nearly at the end of their pregnancy, their delivery date might be brought forward. 

Each case is different, and it is up to the mother and her doctor to decide what course of action to take for the sake of herself and the baby. 

Is it safe to have cancer treatment during pregnancy?

Although mothers-to-be will be deeply concerned about whether cancer treatment will impact their unborn child, they can be reassured that a multidisciplinary team, made up of an oncologist, nurse, obstetrician and midwife, will determine the best thing to do to keep you both safe. 

The treatment or medication you are given will depend on the stage of the pregnancy, the type of cancer and how far it has spread, how quickly it is growing, and whether you are hoping to control the cancer or cure yourself of it. 

For those with early stage cancer or a tumour that is slow growing, it might be advised to delay the treatment until after the baby is born and let the doctors monitor its growth in the meantime. 

However, if your oncologist recommends starting treatment before you deliver, there are a few options available. 

What cancer treatment is safe during pregnancy?

 

Chemotherapy

After 14 weeks, it is typically considered safe to have chemotherapy, which is why it is commonly used for those with breast and cervical cancers, as well as lymphomas and leukemias, while pregnant. 

While it carries the risk of birth defects or loss during the initial three months, after the first trimester it is thought to be a low-risk option, as the placenta is fully developed and is able to block the majority of the drugs from passing through. 

According to Cancer.net: “Studies suggest that children exposed to chemotherapy during pregnancy do not show more health issues than children who are not. This includes right after birth and during the child’s growth and development.”

Towards the end of the pregnancy, chemotherapy could lead to a risk of infection for the baby and makes it more likely there will be bleeding during birth. That is why it is normally stopped three to four weeks before the baby is due. 

 

Radiotherapy

Radiotherapy is not usually given during pregnancy, particularly if the tumour is close to the baby, as a result of the radiation exposure. This could result in miscarriage, and birth defects, as well as slow the growth of the foetus and increase the chance of childhood cancer. 

If the tumour is in a part of the body that is away from the foetus and the doctors consider it safe to go ahead with the treatment, radiotherapy is typically conducted during the early part of pregnancy as the baby is smaller. 

Alternatively, radiation therapy might be delayed until after the baby is born. 

 

Hormone therapy

Hormone therapy is commonly given to treat breast cancer, but this is not given during pregnancy as it can cause birth defects. Therefore, pregnant mothers wait until after they deliver their baby before starting the drugs. 

Immunotherapy and targeted drug therapy are also usually avoided during pregnancy as they might cause harm to the baby. 

 

Surgery

Cancer patients who require surgery can go ahead with the procedure during pregnancy, as the risk to the foetus is low. 

A general anaesthetic will not usually be given until 14 weeks, so some women might have to wait until they are through the first trimester before they can have surgery. 

What happens after the baby is born?

After the baby is born, some women will have to either start or continue their cancer treatment. This, along with looking after a newborn baby, can be extremely challenging. 

This is particularly the case if they need to deliver their baby early to start their treatment, and, subsequently, their child has to be cared for in neonatal intensive care units. 

It is important to make the most of the support from friends and family, and the multidisciplinary team that is taking care of you and the baby at this difficult time.

Do All Cancer Patients Need Chemotherapy As Their Treatment?

Chemotherapy is perhaps the best-known form of cancer treatment, as the intense drug destroys cancer cells and prevents any more from growing. 

While the drug, which can be taken orally or injected into the blood, can be used on a huge variety of cancers, not everyone who receives a diagnosis will need a course of chemotherapy. 

As it gets directly into the bloodstream to damage as many cancer cells as possible around the body, it is an effective treatment for blood cancers. Therefore, those with leukaemia and lymphomas are more than likely to receive a course of chemo. 

Chemotherapy can also be used to reduce the number of cancer cells before surgery or radiotherapy, treat advanced stages of cancer, or slow down the spread of cancer. In these cases, it can be used for any type of cancer, depending on how far along the patient is. 

Some doctors will also recommend having chemotherapy after surgery or radiotherapy to reduce the risk of it coming back. 

However, if a cancer has been detected early and the surgeons are confident they can remove the tumour entirely, chemotherapy might not be required. 

Additionally, there are some types of cancer that do not respond well to chemotherapy. 

Another reason why oncologists might not recommend chemotherapy to some patients is due to its many adverse side-effects, from fatigue to an increased chance of infection, vomiting to concentration struggles, and nerve damage to anaemia. 

If the doctor thinks the patient is not well enough to handle these side-effects, whether they are too old or their organs would not be able to cope with the extra strain, they might not be put forward for the treatment. 

Doctors will look at the type of cancer, how advanced it is, and the health condition of the patient to determine whether chemotherapy is the right course of action to take.

Could Artificial Intelligence Help With Cancer Diagnoses?

In a year in which one of the most widely-discussed technologies in the medical world has been artificial intelligence, the potential for machine learning and AI’s use to help accelerate analysis and tests by private oncologists is profound.

A few years ago, there was the famous story of how a Japanese AI-powered bread scanner was adapted to help doctors check for cancerous cells, and since then many other attempts have been made to boost the potential of diagnostic equipment through AI.

A suitably trained machine learning algorithm could be used by a doctor to highlight potentially worrying signs for a doctor to check, or provide a second opinion in edge cases if a doctor needs to examine a test further.

This potential has been established in several studies, but the question remains about its use in the wider oncology world.

Ultimately, as with any other medical instrument, AI could be beneficial if not outright revolutionary as long as developers, regulators and oncologists alike are appropriately prepared.

There needs to be a robust training system and continuous professional development to allow skilled medical staff to advance their skills with digital tools and AI, in order to feel confident enough to use them in critical situations.

There also needs to be an interoperable infrastructure such as the Welsh Clinical Portal that allows for imaging databases, electronic patient records and test results to be accessed by AI tools and build up the required context to interpret test results.

It also needs to be a system that makes the lives of patients and doctors easier, which includes clear communications of the capabilities of AI and developing trust that data is only used in ways that patients consent to.

Finally, it needs to narrow the gaps in the healthcare system rather than widen them, which means using diverse datasets to train AI and avoid potential biases, as well as ensuring it is accessible across Sheffield and the United Kingdom.

How AI Will Play A Vital Role Within Oncology In The Future

In recent years, the field of medical science has witnessed a seismic shift with the emergence of artificial intelligence (AI). While the impact has been substantial across various domains, perhaps nowhere is its promise more evident than in the fight against cancer.

From predictive analytics to personalised treatment plans, AI is poised to revolutionise cancer prevention and treatment. In this blog post, we will explore how it is rapidly advancing in the quest to prevent and treat cancer, and what the future holds for this groundbreaking technology.

 

The Speed Of AI Advancement

AI’s progress within the healthcare sector, including oncology, has been nothing short of remarkable. Machine learning algorithms can analyse vast datasets at speeds that were previously unimaginable. This accelerates the identification of patterns and potential risk factors associated with cancer.

It can process large volumes of data, including genomics, medical records and clinical trials, at a rate that would be impossible for humans. This, in turn, expedites the discovery of new insights and the development of novel treatment approaches.

 

Current And Future Implementations

Early Detection: It is aiding in the early detection of cancer by sifting through medical images, such as mammograms and MRIs, to identify even subtle abnormalities. This early diagnosis can significantly improve survival rates.

Personalised Treatment: AI analyses a patient’s genetic makeup and medical history to create personalised treatment plans. This ensures that treatments are tailored to individual patients, maximising their effectiveness while minimising side effects.

Drug Discovery: It can analyse massive datasets to identify potential drug candidates. This speeds up drug development and the identification of targeted therapies for specific cancer types.

The integration into cancer prevention and treatment is an ongoing journey and the possibilities are limitless. As technology continues to evolve and improve, it’s becoming increasingly clear that AI is set to be a critical tool in the fight against cancer.

The collaboration between scientists, clinicians and AI experts promises a future where the prevention and treatment of cancer are more efficient, effective and patient-centred than ever before. While it is not a panacea, its ability to process information at unprecedented speeds and tailor treatments to individual patients offers renewed hope in the battle.

Is Cryotherapy Used To Treat Cancer?

There are a lot of unique, experimental and innovative treatments used in private oncology to help treat cancer, but the three main types are conventional surgery, chemotherapy and radiotherapy.

These treatments have been used for nearly a century and the effectiveness of these treatments for most forms of cancer is well-established, so an oncologist can recommend certain treatments or courses of treatment over others.

However, one of the most unique treatments is the opposite of radiotherapy, where instead of burning the cancerous tumour or lesion using a beam of radiation, liquid nitrogen or exceptionally cold argon gas is used to freeze the cells and destroy them that way.

A cryotherapy treatment is the use of extreme cold to destroy precancerous conditions, lesions, tumours and some types of cancers.

Typically it is used for some types of basal cell skin cancer, where it takes the form of liquid nitrogen that is carefully applied to the cancerous area. Liquid nitrogen is cooled to a temperature far lower than the cells will survive, causing the cancer to die.

Alternatively, it can be used for some types of cervical cancer, liver cancer, kidney cancer or lung cancer that has reached an advanced stage, with a clinical trial taking place to see if it is effective at treating prostate cancer.

In these cases, it takes the form of an argon gas that is carefully inserted into the body using a cryoprobe. This carefully freezes the cancer cells from the inside and destroys them.

This process is repeated until cell death is achieved.

It is generally effective as long as the area in question has strong blood circulation. The cold causes blood vessels to constrict, and if there is a poor flow of blood, it can cause tissue to die in the surrounding area unintentionally, similar to the care put into radiotherapy treatments.

Can Breast Cancer Awareness Month Help Save More Lives?

October is Breast Cancer Awareness Month, an annual event that cancer charities hope will help to save lives by ensuring patients can spot the signs of disease early and encouraging fundraising for research.

Like any kind of cancer, early diagnosis is the key to survival, so those getting private treatment for breast cancer could give themselves the very best chance by knowing how to spot any anomaly and getting checked out promptly.

This year’s Breast Cancer Awareness Month has a particular focus on secondary breast cancer. Breakthrough Breast Cancer has said 61,000 patients in the UK have been diagnosed with the condition.

Secondary breast cancer is defined as cancer that has spread well beyond the breast to other parts of the body by the time it has been diagnosed. By that stage it is incurable, but not untreatable, with the priority of treatment being to sustain life as long as possible while maintaining a reasonable quality of life too.

This means the focus of research is better treatments for the condition that can lengthen life and a greater general understanding of the condition.

As ever, the month will see plenty of fundraising efforts and events, with lots of pink items being worn along the way. But the best thing that can come out of it for today’s patients – as opposed to those who may benefit from future medical developments – is awareness of the need to carry out self-examination and what the possible signs of a problem could be.

Around one in seven women in the UK are diagnosed with breast cancer in their lifetime. But those who receive the diagnosis early can survive through surgery and, if required, chemotherapy or radiotherapy.

That is why it is vital to get screened and checked for lumps, as well as seeking the best treatment as soon as you can.

Understanding How To Receive The Best Cancer Treatment

When you or a loved one is diagnosed with cancer, you first want to understand the available treatment options. The main modalities used in treatment are surgery, chemotherapy, radiation therapy, immunotherapy and targeted therapy. We will outline these treatments and what they offer in order for you to receive the best treatment.

Surgery aims to remove the tumour and any surrounding cancerous tissue. It can be used alone or in combination with other treatments. The goal of surgery is to remove all detectable cancer cells. Depending on the type and stage of cancer, surgery may be able to cure the disease.

Chemotherapy uses anti-cancer drugs to stop the cells from reproducing, which prevents spreading in the body. It can be administered intravenously or orally in the form of pills. Chemotherapy is usually used as an adjuvant treatment before or after surgery to help reduce the risk of recurrence. It may also be used as a primary treatment to shrink tumours.

Radiation therapy uses high-energy radiation beams to kill cancer cells and shrink tumours. It works by damaging cancer cell DNA preventing them from dividing. Radiation can be delivered externally by a machine outside the body or internally through radioactive seeds or wires placed inside or near the tumour.

Immunotherapy uses the body’s immune system to help it identify and attack cancer cells more effectively. These include monoclonal antibodies, checkpoint inhibitors and vaccines. Some types of immunotherapies are also called targeted treatments. While this isn’t available for all types of cancer, active research and development seeks to expand this.

Targeted therapy uses drugs that specifically target proteins that control how cancer cells grow, divide and spread. This procedure causes minimal damage to healthy cells through small-molecule drugs which are small enough to enter cells easily, so they are used for targets that are inside cells.

Understanding the basic differences between these treatments empowers you to have more informed conversations with your loved ones or an oncologist. They will help determine the best protocol or combination of therapies based on the unique characteristics of cancer and the patient in order to minimise negative side-effects.

Can You Do Exercise Whilst Undergoing Cancer Treatment?

It goes without saying that being physically active has a considerable number of benefits for both physical wellbeing and mental health, and that includes reducing the risk of getting certain types of cancer.

According to Cancer Research UK, physical activity can reduce the risk of contracting 16 types of cancer, and most people try to maintain an active lifestyle, which leads to one of the most common questions asked of oncologists when a treatment schedule is being finalised.

People want to know if they can exercise or continue to exercise whilst undergoing treatment, and the answer in almost every case is an emphatic yes. Not only is exercise during cancer treatment typically fine, but it can help to improve a person’s quality of life during treatment.

Exercise can help not only in the most obvious way of keeping the body moving, joints from locking up and blood pumping, but it can also help to reduce fatigue, one of the most common side effects of treatments like chemotherapy.

It can also help people to improve their mood, keep their spirits high, soothe anxiety and reduce depression.

Naturally, it is important for any patient going through cancer treatment to ask their oncologist first to make sure they are okay to exercise, and they need to be mindful that they may need to be careful about pushing themselves to their limits.

There are certain types of cancer treatments and complications that can either reduce one’s ability to exercise or means they have to take extra precautions.

For example, people undergoing treatments for bone cancer need to be very careful with the exercises they do to avoid putting undue stress on the bones and risking breakages.

Yoga, aqua aerobics and swimming are gentler alternatives that do not stress bones as much.

Similarly, people with peripheral neuropathy, often manifesting in pins and needles may have issues controlling weight machines and may be best sticking to stationary bikes and other similar devices.

As well as this, people recovering from surgery should ask their doctor when they can start exercising again in order to avoid placing too much stress on surgical scars.

Finally, people should avoid public gyms at first if they are undergoing treatments that affect their immune systems, such as chemotherapy, radiotherapy and immunotherapy.