Cancer is a group of more than 100 different diseases characterized by the uncontrolled, abnormal growth of cells. Normally, the body can kill abnormal cells or stop them from dividing, but sometimes they keep growing and form a tumor. Cancer can move through the blood and lymph systems and spread to other parts of the body.
In most people with cancer, it is easy for doctors to identify the primary site (where the cancer began), and the secondary or metastatic site (if the cancer has spread and where). No matter where the cancer spreads to, the cancer is still described by the primary site. For example, breast cancer that has spread to the brain is called metastatic breast cancer, not brain cancer.
In less than 5% of all people diagnosed with cancer, the cancer is found at a metastatic (secondary) site but routine testing cannot locate the site where the cancer began. These cancers are called carcinoma of unknown primary site or cancer of unknown primary (CUP). In some people, specialized testing can identify the primary site; however, in many cases, it cannot. This may be because the primary tumor remains very small, the body is able to cause the primary tumor to shrink or disappear, and/or the primary tumor was removed during previous surgery for another condition, such as a mole on the skin or a hysterectomy (surgery to remove a woman’s uterus).
Statistics
CUP accounts for approximately 2% to 5% of cancers diagnosed in the United States each year. The average age of a person diagnosed with this type of cancer is about 60, and CUP is slightly more common in men than in women.
People with CUP are a diverse group, and prognosis (chance of recovery) varies widely. Often, treatments are limited for people whose cancer is widespread at the time of diagnosis. However, others have a cancer that can be successfully treated; for some, curative therapy is available. These differences and survival rates are discussed in the Treatment section.
Cancer survival statistics should be interpreted with caution. Estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with CUP.
Statistics adapted from the American Cancer Society.
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
Since CUP can be almost any type of primary cancer, the risk factors for all types of cancer are relevant. The following factors can raise a person’s risk of developing CUP:
Age, as the average age of a person diagnosed with CUP is 60
Tobacco use, including cigarette smoking, chewing tobacco, and cigar smoking
Extended exposure to the sun
Exposure to large amounts of radiation
Exposure to chemicals in some manufacturing industries
Poor nutrition
Lack of exercise
Family history (Specifically, if more than one brother, sister, parent, or grandparent has had breast, ovarian, or colorectal cancer, the risk of cancer increases.)
Since CUP can appear anywhere in the body, the initial symptoms can vary. Usually, symptoms are related to the area where the cancer is found, most commonly the liver, lungs, bones, and lymph nodes. People with CUP may experience the following symptoms. Sometimes, people with CUP do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.
Persistent pain in a specific area of the body
Loss of appetite or unexplained weight loss
Persistent cough or hoarseness
Thickening or lump in any part of the body
Changes in bowel or bladder habits
Unusual bleeding or discharge
Persistent fever or night sweats
Even when the primary site cannot be identified, signs and symptoms can often help the doctor plan effective treatment. Careful evaluation and testing of the tumor tissue removed during the biopsy (see Diagnosis) can sometimes provide clues about where the tumor began. Also, identifying where the cancer has spread can help identify which treatments are most appropriate.
By definition, CUP is found after it has metastasized beyond its place of origin. Doctors use many tests in an effort to locate the primary site. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. Imaging tests will likely be used to look for additional areas where the cancer has spread.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease; see below). The type of biopsy performed will depend on the location of the cancer.
Evaluation by a pathologist
A pathologist makes the diagnosis of cancer by examining a sample of the tumor obtained through a biopsy. The results of the initial biopsy provide important information and guide further evaluation. Most cases of CUP fall into these four categories:
Adenocarcinoma. Nearly 60% of all cases of CUP are adenocarcinoma. Adenocarcinoma can arise in most internal organs (for example, lung, stomach, pancreas, colon, ovary, and breast). When found in a metastatic site, it is extremely difficult for the pathologist to tell the site of origin.
Poorly differentiated carcinoma. Nearly 20% to 30% of all CUP cases are poorly differentiated carcinomas. These cancers require extra tests by the pathologist, since some very treatable cancers may initially be diagnosed as poorly differentiated carcinoma. If testing identifies lymphoma, germ cell carcinoma, or neuroendocrine carcinoma, effective treatments are often available. When evaluation does not identify more specific tumor types, some patients with poorly differentiated carcinoma may still be treated successfully with chemotherapy.
Squamous cell carcinoma. Nearly 5% to 10% of all CUP cases are squamous cell carcinoma. Effective treatments are available for tumors with certain characteristics. If squamous cell carcinoma involves the cervical (neck) lymph nodes, the primary site is often in the head and neck area. If it involves the inguinal (groin) lymph nodes, the primary site may be in the vulva, vagina, cervix, anus, or bladder. A careful search is important, since most of these cancers can often be treated successfully.
Neuroendocrine carcinoma. Nearly 1% to 5% of all CUP cases are neuroendocrine carcinoma. These cancers are being recognized more frequently when specialized pathologic staining is performed. Some of these tumors are aggressive and fast growing, but are responsive to combination chemotherapy. Others are very slow growing, and patients sometimes live for several years even without treatment.
Clinical evaluation (evaluation by an oncologist)
Once a diagnosis of CUP is made, an oncologist (a doctor who specializes in treating people with cancer) will do further tests to search for the primary site and to determine how far the cancer has spread. However, most patients with CUP, the primary site is not found even after extensive evaluation. For this reason, several diagnostic tests (described below) may be done in order to evaluate specific signs and symptoms. The following tests may be recommended:
Medical history. The doctor will ask detailed questions about previous illnesses, surgeries, and medications. The doctors can help more if they also know as much information as possible about smoking history, drug use, previous moles or benign (noncancerous) tumors, and any exposure to radiation, asbestos, or other known dangerous chemicals. Family history of cancer may also provide important clues, especially if one or more siblings, parents, or grandparents have had breast, ovarian, or colorectal cancer.
Physical examination. The doctor will do a thorough physical examination of the entire body, including lymph nodes, pelvis, breasts, rectum, and genitals.
Blood and urine tests. These tests can tell if certain tumor markers and proteins are present that may help identify where the cancer began. Tumor markers are substances found at higher than normal levels in the blood, urine, or body tissues of some patients with cancer. Tumor markers are produced either by the tumor or by the body as a result of cancer or other conditions. For example, presence of the Epstein-Barr virus (EBV) may indicate nasopharyngeal cancer in patients who have cancer in the neck lymph nodes. Elevated levels of the proteins human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) may lead to the diagnosis of germ cell tumor in young men with poorly differentiated carcinoma.
X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
Computed tomography (CT or CAT) scan of the chest and abdomen. A CT scan helps doctors determine the location and extent of the cancer. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. The CT scan can show cancer in other parts of the abdomen and chest.
Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. PET scans have proven useful in detecting a primary site in 20% to 30% of patients with CUP. For this reason, the PET scan is now considered a routine part of the initial evaluation. Even when a primary site is not identified, a PET scan can sometimes provide information that is useful in treatment planning. For example, in patients who have a single area of cancer involvement where local treatment (surgery or radiation therapy) is being considered, a PET scan can rule out other unsuspected areas of cancer involvement. When used in conjunction with CT scans, the information obtained is more detailed and specific than that obtained with either scan alone.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the tissues or organs being studied. This substance gives off energy that is detected by a scanner, which produces the images. In some parts of the body, especially the brain and vertebral column, the MRI scan provides more information than the CT scan. In addition, women with cancer in the axillary lymph nodes (under the arm) should have a breast MRI scan, since this test can sometimes detect a small breast cancer that goes undetected by a mammogram (x-ray of the breast; see below).
Endoscopy. This test allows the doctor to see inside the body. The person may be sedated, and the doctor inserts a thin, lighted, flexible tube called an endoscope through the mouth and down the esophagus. The specific procedures are named according to the part of the body. For example, a bronchoscopy allows doctors to look inside the bronchial tubes (lungs), and a colonoscopy allows doctors to look inside the colon and rectum. Endoscopy is used in patients with CUP to evaluate the specific symptoms. For instance, patients with squamous cell carcinoma involving neck lymph nodes should always have a complete endoscopy of the nasopharynx, throat, and larynx (voice box) to search for a primary site.
Prostate-specific antigen (PSA) test. Prostate-specific antigen (a type of protein released by prostate tissue) is a substance found in a man's blood when there is abnormal activity in the prostate, including prostate cancer, benign prostatic hyperplasia (BPH), or prostatitis (inflammation of the prostate). Men who are experiencing bone pain will have a PSA test. A PSA test detects higher than normal levels of PSA, which may indicate the presence of prostate cancer.
Mammogram. Women may receive a mammogram (x-ray of the breast), especially if they have cancer in the axillary lymph nodes or other areas that might suggest metastatic breast cancer (for example, fluid around the lungs or bone involvement).
When the clinical and pathologic evaluation is finished, answers to the following questions are essential in helping doctors plan treatment:
Did the clinical and imaging evaluation succeed in locating a primary site? If so, treatment should proceed according to guidelines for an advanced (metastatic) tumor of that primary site.
Did the pathologic (biopsy) evaluation identify a specific tumor type (for example, lymphoma or germ cell tumor) or a primary site? If so, treatment should follow guidelines for the specific tumor type.
If no primary site was identified, does this CUP fit into any of the subgroups for which specific treatment is recommended (see Treatment)?
If no primary site was identified and this CUP does not fit any of the subsets with specific treatments defined, will chemotherapy (based on the doctor’s experience and evaluation of each patient individually) be beneficial? The chance of chemotherapy being successful depends on the location of the tumor, number of tumors involved, and the person's overall health at the time of diagnosis.
The treatment of CUP depends on the size and location of the tumor, where the cancer has spread, and the patient’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. Since CUP has usually spread to more than one place at the time of diagnosis, this tumor can rarely be removed surgically or treated with localized radiation therapy. However, CUP may respond well to treatment with chemotherapy, and some tumors can be even fully eliminated.
This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than the standard treatment. Your doctor can help you review all treatment options. For more information, visit the clinical trials section.
A description of each treatment option is below, followed by an outline of treatment by CUP subgrouping.
Surgery
A surgeon will perform an operation to remove the tumor and an area of tissue around the tumor (called a margin). The extent and location of the surgery depends on where the cancer is found and its size.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells.
The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered throughout the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Treatments by CUP subgroup
The following subgroups can often be identified by the initial clinical and pathologic evaluation (see Diagnosis) and have recommended treatments:
Women with adenocarcinoma limited to the axillary lymph nodes. Treatment should follow guidelines for stage II breast cancer, even if no primary site in the breast can be identified. Local treatment should include mastectomy (surgical removal of the breast) or axillary node dissection (surgical removal of the lymph nodes) plus radiation therapy to the breast. Adjuvant treatment (treatment after surgery) with chemotherapy and/or hormone therapy should also be recommended, depending on the number of involved lymph nodes, the estrogen/progesterone receptor status, the HER2 status, and other features of the tumor.
Women with peritoneal carcinomatosis (adenocarcinoma involving the surface of the abdominal cavity). Treatment should follow guidelines for stage III ovarian cancer, even in women with normal ovaries or whose ovaries have been removed. When possible, debulking surgery (initial surgery to remove as much of the cancer as possible) should be performed. Chemotherapy with a taxane/platinum combination should follow surgery, as in ovarian cancer treatment. CA-125 is often a useful tumor marker for monitoring the treatment’s effectiveness. Approximately 20% to 25% of women in this group have long-term survival.
Young men with poorly differentiated carcinoma involving the mediastinum (center of the chest between the lungs) or retroperitoneum (back of the abdominal cavity). Some men in this group may have germ cell tumors, even if the diagnosis cannot be made. Elevated levels of HCG and AFP in the blood strengthen this possibility. Initial chemotherapy should follow guidelines for treatment of advanced testicular cancer. Surgical resection (removal) of the remaining tumor after chemotherapy is often necessary. Cancer can be successfully treated in about 30% of men in this group.
Squamous cell carcinoma involving the cervical (neck) lymph nodes. Even if a careful search does not reveal a primary site in the head and neck, these patients should receive treatment according to guidelines for locally advanced head and neck cancer. This usually includes concurrent (given at the same time) treatment with radiation therapy and chemotherapy. In some patients with small, involved cervical lymph nodes, treatment with radiation therapy alone, or surgery followed by radiation therapy, is sufficient. About 40% to 60% of patients in this group have long-term survival.
Squamous cell carcinoma involving the inguinal (groin) lymph nodes. Local treatment should include a lymph node dissection (removal of all inguinal lymph nodes) or radiation therapy. Chemotherapy given at the same time as radiation therapy should also be considered.
Patients who have only a single metastasis. This includes a broad range of patients, since the single metastasis may be found in any number of locations (for example, lymph nodes, brain, lung, or liver). Depending on the location, treatment should include either surgical removal of the tumor or radiation therapy. Most patients in this group eventually have metastases in other locations, but often after a long time without any disease.
Men with metastases limited to the bones and/or an elevated PSA level. These patients should be treated with hormone therapy, in line with treatment recommendations for advanced prostate cancer.
Patients with adenocarcinoma involving the liver and/or abdomen. In some patients where the tumor spread is limited to the abdomen, special pathology tests suggest that the cancer started in the colon. Patients should receive treatment following guidelines for advanced colon cancer.
Patients with poorly differentiated neuroendocrine tumors. Although the primary site usually remains unknown, these types of neuroendocrine tumors usually respond to chemotherapy with platinum/etoposide (Etopophos), with or without taxane (paclitaxel [Taxol] or docetaxel [Taxotere]). This treatment is effective in shrinking the cancer, with resulting improvement in cancer-related symptoms, in about 60% of patients. A smaller percentage (10% to 15%) of patients in this group have complete shrinkage of cancer with chemotherapy.
Patients with poorly differentiated carcinoma. Patients in this group have tumors of many types, and chemotherapy is sometimes successful. Certain clinical factors (such as tumors located only in lymph nodes, two or fewer areas of metastasis, and younger age) are associated with better outcomes with chemotherapy. Clinical trials should be offered to all patients in this group.
Chemotherapy for those not in a CUP subgroup
For a patient who cannot be classified into any of the subgroups above, highly successful treatment is less frequent. However, many patients can benefit in some way from chemotherapy. Several combinations of chemotherapy have been researched and evaluated in patients with CUP. Usually, these chemotherapy treatment plans contain drugs known to be effective against a variety of cancer types. In particular, combination chemotherapy containing newer drugs have resulted in improved success rates and fewer side effects.
Although curative treatment is only seen in about 5% of patients given chemotherapy, it produces shrinkage of tumors in about 35% to 40% of patients, and 20% to 25% of patients live two years or more. After about four to six weeks of treatment, it is clear which patients are benefiting from treatment; those patients will continue treatment for four to six months. Even for patients whose tumors do not respond to chemotherapy, treatments are available to reduce symptoms.<</p>
All patients with CUP should always ask about the availability of clinical trials evaluating new drugs or drug combinations. Many new drugs are now being evaluated, and it is likely that some of these will improve the treatment of patients with CUP.
Doctors and scientists are always looking for better ways to treat patients with CUP. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy drugs, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that this is the only way to make progress in treating CUP, such as finding new drugs. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with CUP.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects, based on ASCO’s curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
After treatment for CUP ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.
Since patients with CUP are a diverse group of people and recommended treatments vary, the acute (short-term) and chronic (long-term) effects of treatment differ. In addition, recommended follow-up and long-term prognosis varies from person to person. Recommendations in this section are directed primarily to patients who received successful treatment.
For patients in specific, treatable subgroups (see Treatment) who receive treatment following guidelines established for various cancers of a known primary site, the side effects and after-treatment recommendations are similar to that specific cancer. Please refer to the specific cancer type section for more information.
For patients who receive chemotherapy and experience remission (temporary or permanent absence of symptoms), treatment is usually stopped after four to six months. Most of the treatment-related side effects (for example, low blood counts, fatigue, weakness, and joint aches) go away within four to six weeks after treatment. However, peripheral neuropathy (numbness or discomfort in the hands and feet) improves slowly and may take six to 12 months to go away.
Close follow-up care is recommended during the first year after treatment ends, with physical examinations and routine laboratory tests every two months, and appropriate x-rays/scans every three to four months. Any new symptoms should be reported to the doctor right away.
People recovering from CUP are encouraged to follow established guidelines for good health, such as avoiding, maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help you rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Research for CUP is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.
Gene expression profiling for diagnosis of the primary site. All cancer cells have abnormalities in the expression of certain genes and proteins. In fact, some of these abnormalities are important in making the cell act like a cancer cell, rather than a normal cell. With improved methods of finding and evaluating these gene abnormalities, it appears that cancers starting from different sites have different patterns of gene abnormalities. For example, a cancer starting in the lung has a different profile of abnormal gene expression than does a cancer arising in the colon or elsewhere. It is likely that testing for the gene expression profile in tumor biopsies from patients with CUP will result in the identification of the primary site in some patients. Several such diagnostic tests are currently being evaluated.
For patients who cannot be classified into any identified CUP subgroups, the following types of clinical trials are being conducted in an attempt to identify more effective treatment:
New combinations of chemotherapy drugs. Many of these clinical trials are attempting to apply treatment programs already found effective in other types of cancer. Some of the studies are testing new drugs (for example, drugs not yet approved by the U.S. Food and Drug Administration [FDA]), while others are studying new combinations or new schedules of approved drugs.
Combinations of chemotherapy and targeted therapies. Many of the newer cancer treatments involve drugs targeted against newly discovered abnormalities specific to cancer cells, called targeted therapy. Several of these agents are already FDA-approved for specific cancers, usually in combination with chemotherapy. Two such drugs, bevacizumab (Avastin) and erlotinib (Tarceva), have demonstrated some activity when used together in patients with CUP. These and other new agents are being further studied in clinical trials.
Treatment with new investigational (phase I) agents. Testing of very new cancer agents (phase I clinical trials) is usually performed in patients whose cancers are resistant to standard treatment. The goals of these studies are to identify the toxicities and optimal doses of these drugs, as well as to get a preliminary idea of whether there is effectiveness against cancer.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
During the initial evaluation/staging
What are the results of the biopsy?
Can you explain my pathology report to me?
Have specialized tests been done by the pathologist to help find the primary site?
What tests or scans are available to help identify a primary site?
Is another biopsy necessary to provide the pathologist with an optimal specimen to examine?
Should I get a second opinion?
Who will be part of my health-care team, and what does each person do?
Before receiving treatment
Does my cancer fit into any of CUP’s identified “subgroups”?
What are the treatment options?
What clinical trials are open to me?
What treatment plan do you recommend? Why?
What is the goal of this treatment?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
What is my prognosis?
What follow-up tests will I need, and how often will I need them?
What support services are available to me? To my family?
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