A National Cancer Institute-designated Comprehensive Cancer Center

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Division of Thoracic Surgery

The Division of Thoracic Surgery employs the latest and most effective surgical techniques in treating chest diseases such as lung and esophageal cancer, chest wall cancer, pleural cancers (including mesothelioma) and mediastinal tumors. Minimally invasive approaches are used whenever possible and may result in quicker recovery times and fewer surgical complications. Patients benefit from an integrated approach to managing conditions affecting the lungs and thoracic cavity: a coordinated effort between all members of the treatment team determines the need for post-surgery follow-up with radiation and/or chemotherapy to ensure the best possible outcomes.

Minimally Invasive Techniques
City of Hope’s minimally invasive techniques play a major role in diagnosis and treatment of lung cancer, ranging from lung biopsy to lung resection, where surgeons use the robotic da Vinci Surgical System.

City of Hope also uses the da Vinci S Surgical System for treatment of esophageal cancer, performing fully-robotic esophagectomy which entails esophagus removal and reconstruction. This procedure offers patients less pain and blood loss, smaller incisions and faster recovery.
 

Lung Cancer Surgery

Lung Cancer Surgery

Staging Procedures
Procedures done to sample lymph nodes and determine the stage of lung cancers
  • Bronchoscopy with Endobronchial ultrasound (EBUS)-  Bronchoscopy involves putting a flexible camera down the mouth and into the  airways. A camera with an ultrasound probe is used for EBUS. This allows the surgeon to see lymph nodes through the windpipe and biopsy them with a needle. There is no incision, and this is done as an outpatient.
  • Cervical Mediastinoscopy- Mediastinoscopy involves making a small incision in the neck and directly removing lymph nodes from around the windpipe, using a camera. It does require an incision, but is also done as an outpatient. Mediastinoscopy has the advantage of getting large pieces of lymph nodes for analysis.
 
Lung Surgery
Surgical excision of lung cancer is usually indicated in early stage lung cancer, sometimes in combination with chemotherapy and radiation. Depending on the location of the tumor, the size of the tumor, and how good the lung function of the patient is, different types of lung resection may be recommended. The mainstay of lung cancer surgery is lobectomy, or removal of a lobe of the lung. A lobe is usually between 10-25% of the lung.  This, as well as other types of lung cancer surgery, can be done through a thoracotomy (incision between the ribs), with thoracoscopy (using three small incisions and a video camera, also known as VATS), or using Robotic-assisted surgery.  Lymph nodes within the chest are typically removed at the time of surgery.
  • Lobectomy- Removal of an entire lobe of the lung (10-25% of the lung)
  • Segmentectomy- Removal of a segment of a lobe of the lung (5-20% of the lung)
  • Wedge Resection- Removal of a piece of lung (smaller than a segment)
  • Pneumonectomy- Removal of the entire lung on one side
  • Sleeve Resection- Removal of part of the airway with or without the lobe of the lung and sewing the airway back together. This procedure is most commonly done to avoid removing the entire lung.
 
Procedures that help symptoms from Lung Cancer
Patients with advanced stage lung cancer can develop symptoms from their lung cancer which can be successfully treated with surgical procedures.
  • Pleurx catheter- Placement of a soft tube in the chest that allows drainage of fluid buildup around the lung at home.
  • Talc Pleurodesis- Treatment of the chest cavity with talc to cause the lung to stick to the chest wall and prevent fluid build up.
  • Airway stenting- A stent can be placed within the airway (windpipe) to improve breathing when the airway is blocked or compressed by a tumor.
  • Laser or removal of airway tumor- A tumor within the airway can be partially removed using different techniques, including lasers, to improve breathing.
 
For additional information on our multidisciplinary team of experts please see our Lung Cancer Program page.
 

Esophageal Cancer Surgery

Esophageal Cancer Surgery
There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma.  The number of patients with adenocarcinoma has been rising over the last several years, particularly among white men.  At City of Hope, we personalize the surgical approach to provide the best treatment for the specific patient.
 
Endoscopic Treatment
Chronic heartburn (gastroesophageal reflux disease) can lead to irritation of the lining of the esophagus.  Over time, this irritation can cause the cells to become pre-cancerous, a condition known as Barrett’s esophagus.  Through an endoscope (small, flexible camera that enters through the mouth), experts at City of Hope can destroy (ablate) this precancerous tissue, allowing the body to lay down a new layer of more normal cells.  We can also remove very early stage cancers with the endoscope, in a technique known as endoscopic mucosal resection.  These endoscopic treatments are outpatient procedures and do not require an overnight stay in most cases.  Patients recover very quickly and usually resume normal activities the next day.  For Barrett’s esophagus and early stage esophageal tumors, these endoscopic treatments are highly effective and have cure rates equivalent to traditional surgery.
 
Minimally Invasive Surgery
Unfortunately, most esophageal cancers are found at a more advanced stage than can be treated with endoscopic therapies.  For these more aggressive tumors, we recommend a radical esophagectomy, which involves removal of most of the esophagus as well as some of the stomach.  Many patients receive a combination of treatments with chemotherapy and radiation before surgery.  In most cases, City of Hope surgeons perform radical esophagectomy using minimally invasive, robotic techniques. 
 
Benefits of Minimally Invasive and Robotic Esophagectomy
Compared to traditional esophagectomy which requires a large abdominal incision, a large chest incision with rib spreading, and sometimes a neck incision, minimally invasive esophagectomy has been shown to cause less pain, less blood loss, a faster recovery, and fewer complications.  There is no difference in the risk of cancer recurrence.
 

Mesothelioma

What is mesothelioma?
Malignant Pleural Mesothelioma is a cancer that arises in the lining around the lungs.  The three main types of mesothelioma are epithelial, sarcomatoid, and mixed types.  The different types respond differently to treatments.
 
Risk Factors
Exposure to asbestos is the main risk factor for mesothelioma.  This can be in the form of personal exposure to asbestos at home or work.  Living with someone who is exposed to asbestos can increase a person’s risk of developing mesothelioma.  It is also possible that a certain virus (simian virus 40) used to make polio vaccine in the past may be linked to mesothelioma.  Radiation exposure may also be a risk factor.  It usually takes many years after the exposure for mesothelioma to develop.

Symptoms
Mesothelioma usually causes fluid to build up in the chest.  This fluid may compress the lung and cause difficulty breathing.  It could also lead to cough and decreased energy.  Patients may also have pain or aching in the chest.

Treatment for Mesothelioma
The goal of treatment in mesothelioma is to help patients live as long as possible with the best quality of life possible.  There is evidence that this is best achieved through a multidisciplinarly approach involving chemotherapy, surgery, and radiation therapy. 

Surgery
The goal of surgical therapy in mesothelioma is to remove all visible tumor from the chest.  Sometimes, this can be achieved by removing the lining around the lungs, while leaving the lungs intact (radical pleurectomy).  Other times, this can only be achieved by removing the lung as well as the lining (extrapleural pneumonectomy).  Both procedures may involve removal of the sac around the heart (pericardium) or diaphragm muscle.   City of Hope surgeons design personalized surgical treatment plans for mesothelioma patients based on the extent of disease.

Chemotherapy
Combination chemotherapy using more than one drug has been shown to help patients with mesothelioma live longer.  For patients who are undergoing surgery, chemotherapy may be given either before or after surgery to help prevent the cancer from recurring .  We also offer clinical trials with new therapies for mesothelioma.

Radiation Therapy
City of Hope’s Intensity-Modulated Radiation Therapy  (tomotherapy) program uses the latest technology with precisely targeted beams to deliver high doses of radiation while minimizing damage to healthy tissue.  This type of therapy helps prevent cancer from recurring after surgery.
 
Clinical Trials
City of hope is one of a handful of medical centers in the United States with active  clinical trials for patients with mesothelioma.
 

Thymoma

What is a thymoma?
Thymoma is a tumor of the thymus gland which is located in the chest behind the breast bone. In children, the thymus gland produces immune cells, but in adulthood the thymus gland no longer serves an important function. Thymomas can be slow growing or can be more aggressive and spread in the blood stream. Thymic carcinomas are the most aggressive tumors of the thymus gland.
 
How is a thymoma diagnosed?
Thymomas may cause symptoms or be found by chance on chest X-rays or CT scans done for other reasons. Thymomas are associated with myasthenia gravis, an autoimmune disease causing muscle weakness. Very large thymomas may also cause symptoms such as cough and shortness of breath. If the thymoma appears small, your surgeon may recommend surgical removal without a biopsy. However, if the tumor is large or if the diagnosis of thymoma is not certain, your surgeon may recommend that you undergo a CT-guided core needle biopsy, which is done in radiology.
 
Stages of Thymoma (Masaoka staging)
  • Stage I: The tumor is contained within the thymus gland
  • Stage II: The tumor invades through the “capsule” of the thymus gland into the surrounding fatty tissue
  • Stage III: The tumor invades into neighboring organs in the chest (such as the lung)
  • Stage IVa: Spread of the tumor into the chest lining or heart sack lining
  • Stage IVb: Spread of the tumor to lymph nodes or to other organs through the blood stream

Treatment of Thymoma
Surgical removal of thymoma is the mainstay of treatment for thymomas that can be completely removed. Patients with stage III and IVa thymoma typically receive chemotherapy prior to surgery, and may receive radiation therapy after surgery. Some patients with stage II thymoma will be recommended to undergo radiation therapy after surgery. At City of Hope, we offer the following types of surgery for thymoma.
 
Minimally Invasive Robotic Thymectomy
The thymoma and entire thymus gland are removed through small incisions in the side of the chest. Most patients with stage I and some with stage II thymoma are eligible for this treatment, depending on the size of the tumor. Most patients are able to be discharged from the hospital the day after surgery.
 
Thymectomy through sternotomy
This more traditional approach involves dividing the breast bone down the middle of the chest. This is often necessary for large tumors or stage III and IVa tumors invading neighboring organs in the chest.
 
Thymectomy for IVa and Recurrent Thymoma
Surgical removal of the chest wall lining and thymoma that has recurred can be successfully accomplished.
 
Clinical Trials
City of Hope is one of a handful of medical centers in the United States with active clinical trials in patients with thymomas. Contact us to learn more.
 
 

Minimally Invasive and Robotic Surgery

Minimally Invasive and Robotic Surgery

City of Hope surgeons use minimally invasive, video-assisted thoracoscopic surgery (VATS), and robotic surgery to diagnose and treat cancer in the chest.  We use these techniques routinely for all stages of lung cancer, esophageal cancer, and thymoma treatment.  Traditional, open techniques for surgery in the chest require a large incision as well as spreading of the ribs.  Robotic surgery allows City of Hope surgeons to perform the same operations, but with smaller incisions and without rib-spreading.  For lung cancer, over 75% of our resections are performed robotically, compared to less than 10% nationally. 
 
Advantages of Robotic Thoracic Surgery compared to open surgery
  • Less Pain
  • Fewer Complications
  • Faster Recovery
  • Better Quality of Life
 
For diagnosis and staging, City of Hope also offers endoscopic procedures, including electromagnetic-guided navigational bronchoscopy, endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), and endoscopic mucosal resection.
 

Thoracic Surgery

Division of Thoracic Surgery

The Division of Thoracic Surgery employs the latest and most effective surgical techniques in treating chest diseases such as lung and esophageal cancer, chest wall cancer, pleural cancers (including mesothelioma) and mediastinal tumors. Minimally invasive approaches are used whenever possible and may result in quicker recovery times and fewer surgical complications. Patients benefit from an integrated approach to managing conditions affecting the lungs and thoracic cavity: a coordinated effort between all members of the treatment team determines the need for post-surgery follow-up with radiation and/or chemotherapy to ensure the best possible outcomes.

Minimally Invasive Techniques
City of Hope’s minimally invasive techniques play a major role in diagnosis and treatment of lung cancer, ranging from lung biopsy to lung resection, where surgeons use the robotic da Vinci Surgical System.

City of Hope also uses the da Vinci S Surgical System for treatment of esophageal cancer, performing fully-robotic esophagectomy which entails esophagus removal and reconstruction. This procedure offers patients less pain and blood loss, smaller incisions and faster recovery.
 

Lung Cancer Surgery

Lung Cancer Surgery

Lung Cancer Surgery

Staging Procedures
Procedures done to sample lymph nodes and determine the stage of lung cancers
  • Bronchoscopy with Endobronchial ultrasound (EBUS)-  Bronchoscopy involves putting a flexible camera down the mouth and into the  airways. A camera with an ultrasound probe is used for EBUS. This allows the surgeon to see lymph nodes through the windpipe and biopsy them with a needle. There is no incision, and this is done as an outpatient.
  • Cervical Mediastinoscopy- Mediastinoscopy involves making a small incision in the neck and directly removing lymph nodes from around the windpipe, using a camera. It does require an incision, but is also done as an outpatient. Mediastinoscopy has the advantage of getting large pieces of lymph nodes for analysis.
 
Lung Surgery
Surgical excision of lung cancer is usually indicated in early stage lung cancer, sometimes in combination with chemotherapy and radiation. Depending on the location of the tumor, the size of the tumor, and how good the lung function of the patient is, different types of lung resection may be recommended. The mainstay of lung cancer surgery is lobectomy, or removal of a lobe of the lung. A lobe is usually between 10-25% of the lung.  This, as well as other types of lung cancer surgery, can be done through a thoracotomy (incision between the ribs), with thoracoscopy (using three small incisions and a video camera, also known as VATS), or using Robotic-assisted surgery.  Lymph nodes within the chest are typically removed at the time of surgery.
  • Lobectomy- Removal of an entire lobe of the lung (10-25% of the lung)
  • Segmentectomy- Removal of a segment of a lobe of the lung (5-20% of the lung)
  • Wedge Resection- Removal of a piece of lung (smaller than a segment)
  • Pneumonectomy- Removal of the entire lung on one side
  • Sleeve Resection- Removal of part of the airway with or without the lobe of the lung and sewing the airway back together. This procedure is most commonly done to avoid removing the entire lung.
 
Procedures that help symptoms from Lung Cancer
Patients with advanced stage lung cancer can develop symptoms from their lung cancer which can be successfully treated with surgical procedures.
  • Pleurx catheter- Placement of a soft tube in the chest that allows drainage of fluid buildup around the lung at home.
  • Talc Pleurodesis- Treatment of the chest cavity with talc to cause the lung to stick to the chest wall and prevent fluid build up.
  • Airway stenting- A stent can be placed within the airway (windpipe) to improve breathing when the airway is blocked or compressed by a tumor.
  • Laser or removal of airway tumor- A tumor within the airway can be partially removed using different techniques, including lasers, to improve breathing.
 
For additional information on our multidisciplinary team of experts please see our Lung Cancer Program page.
 

Esophageal Cancer Surgery

Esophageal Cancer Surgery

Esophageal Cancer Surgery
There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma.  The number of patients with adenocarcinoma has been rising over the last several years, particularly among white men.  At City of Hope, we personalize the surgical approach to provide the best treatment for the specific patient.
 
Endoscopic Treatment
Chronic heartburn (gastroesophageal reflux disease) can lead to irritation of the lining of the esophagus.  Over time, this irritation can cause the cells to become pre-cancerous, a condition known as Barrett’s esophagus.  Through an endoscope (small, flexible camera that enters through the mouth), experts at City of Hope can destroy (ablate) this precancerous tissue, allowing the body to lay down a new layer of more normal cells.  We can also remove very early stage cancers with the endoscope, in a technique known as endoscopic mucosal resection.  These endoscopic treatments are outpatient procedures and do not require an overnight stay in most cases.  Patients recover very quickly and usually resume normal activities the next day.  For Barrett’s esophagus and early stage esophageal tumors, these endoscopic treatments are highly effective and have cure rates equivalent to traditional surgery.
 
Minimally Invasive Surgery
Unfortunately, most esophageal cancers are found at a more advanced stage than can be treated with endoscopic therapies.  For these more aggressive tumors, we recommend a radical esophagectomy, which involves removal of most of the esophagus as well as some of the stomach.  Many patients receive a combination of treatments with chemotherapy and radiation before surgery.  In most cases, City of Hope surgeons perform radical esophagectomy using minimally invasive, robotic techniques. 
 
Benefits of Minimally Invasive and Robotic Esophagectomy
Compared to traditional esophagectomy which requires a large abdominal incision, a large chest incision with rib spreading, and sometimes a neck incision, minimally invasive esophagectomy has been shown to cause less pain, less blood loss, a faster recovery, and fewer complications.  There is no difference in the risk of cancer recurrence.
 

Mesothelioma

Mesothelioma

What is mesothelioma?
Malignant Pleural Mesothelioma is a cancer that arises in the lining around the lungs.  The three main types of mesothelioma are epithelial, sarcomatoid, and mixed types.  The different types respond differently to treatments.
 
Risk Factors
Exposure to asbestos is the main risk factor for mesothelioma.  This can be in the form of personal exposure to asbestos at home or work.  Living with someone who is exposed to asbestos can increase a person’s risk of developing mesothelioma.  It is also possible that a certain virus (simian virus 40) used to make polio vaccine in the past may be linked to mesothelioma.  Radiation exposure may also be a risk factor.  It usually takes many years after the exposure for mesothelioma to develop.

Symptoms
Mesothelioma usually causes fluid to build up in the chest.  This fluid may compress the lung and cause difficulty breathing.  It could also lead to cough and decreased energy.  Patients may also have pain or aching in the chest.

Treatment for Mesothelioma
The goal of treatment in mesothelioma is to help patients live as long as possible with the best quality of life possible.  There is evidence that this is best achieved through a multidisciplinarly approach involving chemotherapy, surgery, and radiation therapy. 

Surgery
The goal of surgical therapy in mesothelioma is to remove all visible tumor from the chest.  Sometimes, this can be achieved by removing the lining around the lungs, while leaving the lungs intact (radical pleurectomy).  Other times, this can only be achieved by removing the lung as well as the lining (extrapleural pneumonectomy).  Both procedures may involve removal of the sac around the heart (pericardium) or diaphragm muscle.   City of Hope surgeons design personalized surgical treatment plans for mesothelioma patients based on the extent of disease.

Chemotherapy
Combination chemotherapy using more than one drug has been shown to help patients with mesothelioma live longer.  For patients who are undergoing surgery, chemotherapy may be given either before or after surgery to help prevent the cancer from recurring .  We also offer clinical trials with new therapies for mesothelioma.

Radiation Therapy
City of Hope’s Intensity-Modulated Radiation Therapy  (tomotherapy) program uses the latest technology with precisely targeted beams to deliver high doses of radiation while minimizing damage to healthy tissue.  This type of therapy helps prevent cancer from recurring after surgery.
 
Clinical Trials
City of hope is one of a handful of medical centers in the United States with active  clinical trials for patients with mesothelioma.
 

Thymoma

Thymoma

What is a thymoma?
Thymoma is a tumor of the thymus gland which is located in the chest behind the breast bone. In children, the thymus gland produces immune cells, but in adulthood the thymus gland no longer serves an important function. Thymomas can be slow growing or can be more aggressive and spread in the blood stream. Thymic carcinomas are the most aggressive tumors of the thymus gland.
 
How is a thymoma diagnosed?
Thymomas may cause symptoms or be found by chance on chest X-rays or CT scans done for other reasons. Thymomas are associated with myasthenia gravis, an autoimmune disease causing muscle weakness. Very large thymomas may also cause symptoms such as cough and shortness of breath. If the thymoma appears small, your surgeon may recommend surgical removal without a biopsy. However, if the tumor is large or if the diagnosis of thymoma is not certain, your surgeon may recommend that you undergo a CT-guided core needle biopsy, which is done in radiology.
 
Stages of Thymoma (Masaoka staging)
  • Stage I: The tumor is contained within the thymus gland
  • Stage II: The tumor invades through the “capsule” of the thymus gland into the surrounding fatty tissue
  • Stage III: The tumor invades into neighboring organs in the chest (such as the lung)
  • Stage IVa: Spread of the tumor into the chest lining or heart sack lining
  • Stage IVb: Spread of the tumor to lymph nodes or to other organs through the blood stream

Treatment of Thymoma
Surgical removal of thymoma is the mainstay of treatment for thymomas that can be completely removed. Patients with stage III and IVa thymoma typically receive chemotherapy prior to surgery, and may receive radiation therapy after surgery. Some patients with stage II thymoma will be recommended to undergo radiation therapy after surgery. At City of Hope, we offer the following types of surgery for thymoma.
 
Minimally Invasive Robotic Thymectomy
The thymoma and entire thymus gland are removed through small incisions in the side of the chest. Most patients with stage I and some with stage II thymoma are eligible for this treatment, depending on the size of the tumor. Most patients are able to be discharged from the hospital the day after surgery.
 
Thymectomy through sternotomy
This more traditional approach involves dividing the breast bone down the middle of the chest. This is often necessary for large tumors or stage III and IVa tumors invading neighboring organs in the chest.
 
Thymectomy for IVa and Recurrent Thymoma
Surgical removal of the chest wall lining and thymoma that has recurred can be successfully accomplished.
 
Clinical Trials
City of Hope is one of a handful of medical centers in the United States with active clinical trials in patients with thymomas. Contact us to learn more.
 
 

Minimally Invasive and Robotic Surgery

Minimally Invasive and Robotic Surgery

Minimally Invasive and Robotic Surgery

City of Hope surgeons use minimally invasive, video-assisted thoracoscopic surgery (VATS), and robotic surgery to diagnose and treat cancer in the chest.  We use these techniques routinely for all stages of lung cancer, esophageal cancer, and thymoma treatment.  Traditional, open techniques for surgery in the chest require a large incision as well as spreading of the ribs.  Robotic surgery allows City of Hope surgeons to perform the same operations, but with smaller incisions and without rib-spreading.  For lung cancer, over 75% of our resections are performed robotically, compared to less than 10% nationally. 
 
Advantages of Robotic Thoracic Surgery compared to open surgery
  • Less Pain
  • Fewer Complications
  • Faster Recovery
  • Better Quality of Life
 
For diagnosis and staging, City of Hope also offers endoscopic procedures, including electromagnetic-guided navigational bronchoscopy, endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), and endoscopic mucosal resection.
 
Quick Links
Department of Surgery
For new patients, please call 800-826-HOPE (4673) or 626-471-7100 to make an appointment.
 

Progress of Cancer Research
Clinical Trials
Our aggressive pursuit to discover better ways to help patients now – not years from now – places us among the leaders worldwide in the administration of clinical trials.
 


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