Tips for a Heart-Healthy Lifestyle

Tips for a Heart-Healthy Lifestyle
by Fernando Boccalandro

As seen in the Odessa American Medical Matters:

http://www.oaoa.com/people/health/medical_matters/article_9f50d2bc-7473-11e7-949a-cfd5af542bd8.html

Taking care of your heart is so important. Here are tips that can help you live a more heart-healthy lifestyle.

  • Check your blood pressure at least once every six months to make sure it is within normal limits and that you do not have hypertension.
  • Know your cholesterol levels. If they are normal, then you should check them at least every three to five years. If not in normal range, check them yearly.
  • Exercise at least 30 minutes daily five days a week. Include moderate exercise such as walking, biking, aerobics, yoga, etc.
  • One can of regular soda has 126 calories of added sugars. Instead of soda, drink water, coffee, unsweetened tea or other calorie-free drinks. When you do drink beverages with sugar, go for milk or all-fruit juices that count toward the daily dairy or fruit intake.
  • It is important for your cardiovascular health to have a good quality of sleep for a minimum of seven to eight hours daily.
  • Be a hero for your heart and stop smoking today. MCH has a FREE Smoking Independence Class every Thursday at 6 p.m. in the MCH Cardiopulmonary Education Room.
  • One in three Americans has prediabetes … and only one in ten knows it. So know your risk for diabetes and get screened for it if you have not done so recently.
  • Eating a healthy diet, exercising regularly and losing weight can prevent diabetes. Diabetes largely is a preventable disease in the majority of patients.
  • Avoid salty processed food such as salty snacks, chips, packaged food and canned soup. Instead opt for fresh, frozen or canned foods without any added sodium, sauces or seasonings.
  • By you becoming your own chef and seasoning your own food at home, you can control how much sodium is used. Try out other herbs and spices to get the kick you want instead of shaking on more salt.
  • If you drink alcohol, do so with moderation. That means up to one drink a day for a woman and two drinks a day for men … as defined by the U.S. Dietary Guidelines for Americans.
  • The majority of the patients that have experienced a heart attack, have had a stent placed in the heart or have had a prior bypass should be taking one low-dose aspirin and a cholesterol medication for the duration of their lifetime. Make sure you discuss this with your doctor.
  • Stress management is very important for a healthy heart. The best ingredients to help manage daily stress levels are following a good diet, having a healthy sleeping pattern and continuing a daily exercise program.
  • Avoid food products with trans fats, which is known to increase your risk of developing heart disease.
  • Good dental hygiene has been associated with a healthy heart as well. Maintain good dental hygiene by brushing your teeth, flossing and visiting your dentist regularly.

 

You can do this. Living a heart healthy lifestyle will make you feel better and you can enjoy the things that are important to you. Take care of yourself … it’s important!

Why Gynecological exams are necessary over the age of 50

Why Gynecological exams are necessary over the age of 50
by Dr. Avelino Garcia

As seen in the Odessa American “Medical Matters”:
http://www.oaoa.com/people/health/article_ac8bab86-6efc-11e7-a82a-cfddeecc16cb.html

Many women feel that there is no longer a need for a gynecologist after childbearing. For women over the age of 50, yearly exams are encouraged and very important. Even if a yearly pap smears are not needed, pelvic and breast exams can give your doctor information to keep you healthy.

Getting a yearly physical exam is so much more than just a pelvic exam and breast exam. A general physical exam begins with a detailed health history, including family history and any health changes that may have occurred. An examination of vital signs, including blood pressure, pulse and oxygen saturation, is also included with a yearly examination. Measurements of your height and weight combine to create your Body Mass Index, or BMI. These numbers can tell a doctor a lot of helpful information regarding your current health.

A pelvic exam can evaluate the condition of your vaginal tissues, cervix, uterus, ovaries and rectum. Even if you no longer have a uterus, a yearly pelvic exam is still encouraged to evaluate vaginal anatomy and pelvic health. If you have a cervix, a pap smear with screening for Human Papilloma Virus (HPV) is collected. A positive HPV test could mean that you are a carrier of the HPV virus and therefore at increased risk of cervical cancer. If your pap smear shows abnormal cells in conjunction with the HPV virus, further testing and treatment may be required. If both pap smear and HPV screenings are negative, it is safe to have a pap smear collected every two to three years. Just as a reminder, even if a pap smear is not required, a yearly pelvic exam still needs to be performed.

Even though it is uncomfortable, a rectal exam is encouraged to check for masses or lesions. A check of your stool for blood can also be done at the same time. Baseline screening colonoscopies are encouraged after the age of 50. However, if there is blood in the stool, a visit to the gastroenterologist is imperative for evaluation of your colon health. Screening colonoscopies are recommended earlier than the age of 50 if there is a history of cancer or colon problems in the family.

A yearly breast examination is performed to evaluate breast health. This examination includes the doctor looking at your breasts and nipples for leakage, lesions, redness, dimpling or other signs that there could be a problem present. The provider then does a manual examination, feeling the breast tissues and the under arms for lumps or masses. A yearly mammogram is recommended after the age of 40, unless a close family history of breast cancer is present. This includes mother and/or sisters with breast cancer.  If there is a close family history, yearly screenings may begin earlier, based on the age of diagnosis.

Bone Density, or DEXA scans, help the provider evaluate your bone health. These tests are generally recommended for those aged 65 or over. These tests are encouraged every two years. It is important to keep bones healthy with Vitamin D and Calcium supplementation as well as regular weight bearing exercise.

Screening blood work can be completed by your primary care provider or your gynecologist. Yearly testing to check iron levels in the blood, cholesterol levels, thyroid levels, and blood sugar levels are some recommended testing. Further blood work can be completed to check for hormone imbalances. The provider may also check your Vitamin D and Calcium levels to help evaluate bone health.

Last, but certainly not least, it is important to discuss required immunizations with your provider. A yearly flu shot is encouraged, especially over the age of 50, unless there is a contraindication. A TDaP (Tetanus/Diptheria/Pertussis) vaccine is required every 10 years. After the age of 65, a one-time pneumonia vaccine is recommended. The CDC recommends that anyone over the age of 60 receive the Shingles vaccine.

It is time to put your health first and get your yearly examination.

Colonoscopy Screening also Serves as Prevention

Colonoscopy Screening also Serves as Prevention
by Ramalinga Kedika

As seen in Odessa American Medical Matters:
http://www.oaoa.com/people/health/article_52319570-69c4-11e7-8283-ab698c8f3406.html

“An ounce of prevention is worth a pound of cure” – Benjamin Franklin.

This is true across the medical field, but especially pertinent when it comes to colon cancer screening. It is a lot easier to prevent colon cancer than to treat it once it occurs.

Colonoscopy is a very powerful screening technique because you can not only diagnose polyps that are precursors to colon cancer, but also remove them during the procedure. It is this removal of polyps which can eliminate colon cancer risk. Approximately 25 to 30 percent of 50 year old patients will have polyps.

The major hesitation people have about colonoscopies is fear of pain during the procedure. Many gastroenterologists are performing this procedure using anesthesia (deep sedation) that allows the patient to not have any awareness during the procedure. Often patients wake up from sedation and are surprised that the procedure is already completed!

Another hesitation I often hear is “Ugh, I have to drink all that stuff.” It’s true that drinking the prep is the hardest part of the procedure, but the laxative preps have improved over the years. A common laxative used in the past was about four liters of a liquid. While this prep is still used, there are newer preps which are half the volume (or even smaller) and easier to consume. The preps are often split-dosed, which means the patient drinks half the prep the night before the procedure and the other half early morning of the procedure. This fact can be reassuring to patients worried about having to drink a lot of liquid in one session.

The procedure is also very safe. The most common complication is bleeding which occurs in up to 0.6 percent of procedures. Most of the time the bleeding will stop on its own. Perforation, which is the creation of a hole or tear in the colon accidentally, is a serious complication but occurs very rarely in about 0.1% of procedures.

Medical testing can be expensive and this can also deter people from having colonoscopies. However, many insurance carriers cover screening colonoscopies because these are considered preventive tests. Colonoscopies may be a part of your insurance plan, so take advantage of this!

 

 

MEDICAL MATTERS: Shoulder pain can be early sign of arthritis or other injury

MEDICAL MATTERS: Shoulder pain can be early sign of arthritis or other injury

As seen in the Odessa American “Medical Matters”: http://www.oaoa.com/people/health/medical_matters/article_6d6d2726-2cef-11e7-9a68-736e9c105440.html

 

MEDICAL MATTERS: Shoulder pain can be early sign of arthritis or other injury
by Dr. James Ingram

Dr. James Ingram is a Board Certified Orthopedic Surgeon and specializes in Sports Medicine.

“I saw my Doctor about my shoulder pain. He took an X-ray and told me ‘nothing is wrong’.”

A more appropriate response would have been, “there’s nothing broken”. Most sources of shoulder pain are not obvious on an X-ray. The shoulder is a remarkable joint with more movement than any other joint in our body. Thus, diagnosis of the specific cause of pain in the shoulder can be difficult.

The earliest signs of arthritis in the shoulder typically appear in the joint connecting the collar bone to the shoulder blade (acromio-clavicular or AC joint). In the absence of injury, this joint can show signs of arthritis on x-ray as early as age twenty-five. Pain associated with this joint is increased with lying on the side, using the arm at shoulder height or higher, pulling things toward you or away from your body. The pain does not make motion impossible but the use of the shoulder increases the pain.

Rotator cuff tears may be partial or complete. Risk factors for rotator cuff problems include male gender, high blood pressure and elevated cholesterol. Trauma is also a major cause, fall on shoulder or outstretched hand, shoulder dislocation, lifting or pulling heavy objects. Partial tears are more painful, full thickness tears result in loss of motion and weakness. Many partial tears do not require surgery. Full thickness tears will not heal without surgery. But with therapy, the patient may regain an acceptable motion and use, depending on the patient’s needs.

A cartilage ring surrounds the socket of the shoulder. This cartilage ring, the rotator cuff and the joint capsule provide a stable joint with an extensive range of motion. Tears of this cartilage ring cause pain and mechanical symptoms. They usually result from shoulder dislocation or an unexpected pulling injury to the arm. The bicipital tendon, one of two tendons to the bicep muscle is attached to this cartilage ring. Tears of the bicipital tendon are common. Usually the result of lifting heavy objects. Tears of this tendon usually do not require surgery. The patient will lose ten to fifteen percent of strength bending the elbow. A cosmetic deformity of the bicep contour will occur, but does not contribute to significant weakness.

The shoulder joint contains cartilage and is prone to developing arthritis. The onset is gradual. Primary complaint is pain. As the arthritis becomes more severe the patient will eventually lose motion. The pain is described as constant, increased with use and many times associated with painful catching and grinding.

Another frequent source of “shoulder pain” is actually referred from the neck. The patient’s neck may not hurt! The pain is typically in the back of the shoulder blade. The majority of time, the pain will go below the elbow sometimes causing numbness and tingling in the fingers. Pain that is solely due to a shoulder problem may go to the elbow but not below. Unfortunately, having an injured shoulder does not mean you don’t also have a neck problem, and vice versa.

The key to minimizing shoulder pain lies in maintaining muscle fitness not only the rotator cuff, but the muscles that stabilize your shoulder blade. The shoulder allows us an incredible ability to perform complex tasks. Shoulder pain consequently can be a source of severe dysfunction.

 

 

MEDICAL MATTERS: Good Nutrition is Vital for Pregnancy

MEDICAL MATTERS: Good Nutrition is Vital for Pregnancy
As seen in the Odessa American “Medical Matters”: http://www.oaoa.com/people/health/article_a63f49c0-0c5c-11e7-ae5b-5f1dde4cc0cb.html

by Dr. Avelino Garcia

Good nutrition is vital for a healthy pregnancy. Between fatigue and pregnancy cravings, it can seem difficult to keep healthy eating habits. Planning healthy meals and staying physically active can help.

Eating five or six small meals daily, rather than three large meals, can help with nausea and can also help pregnant women get extra vitamins and minerals needed for growing babies. Each day, eat foods from the major food groups, keeping fats and sugars in moderation. Fresh fruits and vegetables, whole grains and lean proteins are encouraged. Be sure that red meats are fully cooked, not rare, as this can cause illness in a pregnant woman. Fish and seafood are good sources of protein, but stay away from seafood with high mercury content such as shark, swordfish, king mackerel or tilefish. Limit white (albacore) tuna to 6 ounces weekly.

Hydration is also a key part of proper nutrition. Pregnant women are encouraged to drink at least two liters of water daily. Symptoms of dehydration in pregnancy include thirst, headache and uterine cramping. Sugary and caffeinated drinks increase risk for dehydration, so they are to be avoided.

Staying physically active is one of the healthiest things an expectant mom can do for her unborn baby. Thirty minutes of low intensity exercise, like walking, is encouraged.

Unless an expectant mother has a high-risk pregnancy, exercise can help regulate blood sugar levels, keep blood pressure in the normal range, and minimize abnormal weight gain.

The United States Department of Agriculture has made meal planning easier by creating www.choosemyplate.gov. The website assists everyone, including pregnant women, figure out how to make healthy choices with each meal. According to the American College of Obstetricians and Gynecologists (ACOG) Frequently Asked Questions (FAQ) on Nutrition During Pregnancy, the MyPlate website gives “personalized nutrition and physical activity plans by using the ‘Super Tracker’ program. This program is based on five food groups and shows the exact amounts needed each day from each group during each trimester of pregnancy.”

 

MEDICAL MATTERS: It’s just allergies … or is it?

MEDICAL MATTERS: It’s just allergies … or is it?
As seen in the Odessa American “Medical Matters”: http://www.oaoa.com/people/health/article_df0b9662-06e6-11e7-bbb2-3f66b573b122.html

by Dr. Kevin Benson

Allergies seem to be a big part of our lives here in West Texas. It seems that no matter what the season, or the symptoms, people tend to think it’s their allergies. Or is it? Does it matter?

Environmental allergies are the body’s excessive response to things we need not respond too. For example, pollen is not really a threat to me, but my body responds to it in unhelpful ways. My nose fills with mucous, my eyes get red and itchy, that familiar cough makes its annual return. How do I know it’s my allergies versus a cold I may have been exposed to?

History: Seasonal allergies are just that, they occur at certain seasons. Everyone with allergies is a bit different, but most of us can predict the seasons where we will have trouble. Pollen allergies tend to be in the springtime, fall allergies tend to be more mold and mildew sensitivities, winter allergies are often caused by dust or dust mites blowing around as we turn on our heat. So with experience we know when it’s more likely to be allergies than a viral illness. And also why it’s difficult to know in a baby or young child, since they haven’t had as many seasons of experience to know how they respond to those environments.

Duration: Allergies can linger for weeks, sometimes months. It is very unusual for a cold to last more than a week or two. Sometimes we can be fooled though, as we or our children are recovering from one illness and fall into the trap of another illness; what feels like one illness can be a few separate ones. However, it is common to have one viral infection after another, especially in the wintertime.

Fevers: Allergies do not cause fevers. Fever is the body’s natural response to infection, and allergies are not an infection. However some people will develop secondary infections due to allergies; for instance the congestion caused by seasonal allergies can trigger ear infections or sinus infections. That is why it is always a good idea to treat those allergic symptoms as soon as possible, to prevent them from becoming something more serious.

Remember to use your judgment. If you’re not sure if you or your child has a cold or allergies and the symptoms are getting worse, changing or not improving, there’s no harm in consulting with your medical practitioner. When in doubt, check it out!

 

MEDICAL MATTERS: Preserving your hips and knees

As seen in the Odessa American “Medical Matters”: http://www.oaoa.com/people/health/article_7d318b3e-0111-11e7-9e4a-a381343842e9.html

by Dr. James Ingram

Time takes a toll on our bodies and our weight bearing joints and cartilage are no exception. Watching a youngster spring up from a sitting position at the speed of a slingshot reminds us all of the creaks and squeaks of our aging joints. However, you can take control and slow Father Time with a few key non-operative interventions.

Decreasing weight through exercise has a dramatic effect reducing wear and tear on hips and knees. Just to name a few, it improves circulation and cardiovascular health; helps the management of blood sugar; preserves and maintains joint cartilage. Low impact exercises are key. Stick with cycling, swimming or elliptical and stair stepping machines. The benefit of low impact exercise in addition to weight loss, is a reduction of shear force on weight bearing joints, minimizing cartilage loss and improving flexibility.

Supplements have a huge following but no supplement has FDA approval. Of all the supplements, the only one shown to minimize cartilage loss was Glucosamine. When trying supplements, I suggest avoiding ones with multiple ingredient, ie. Glucosamine, Chondroitin, MSM. If you have an untoward reaction with a multiple ingredient supplement, it’s virtually impossible to determine which ingredient did not agree with you. I recommend starting with Glucosamine because it’s the only one proven to be effective.

Support braces that unload the joint showing signs of wear is another intervention worth consideration. Two options are available; off-loader braces, or lateral wedge orthotics. Off-loader braces are bulky where lateral wedge orthopedics are more discretely worn. Although purely mechanical, both unload the burden to tired joints.

Anti-inflammatory, biologicals and injectable are pharmaceutical approaches to joint health. Non-steroidal anti-inflammatory drugs (NSAIDs) were the corner stone for osteoarthritis and rheumatoid arthritis until biologicals (Embrel, Humira, etc.) were developed. Over-the-counter or prescribed NSAIDs are still extremely effective but create cardiovascular risks, elevate blood pressure, can cause stomach ulcers, and even kidney failure. Injectable intervention falls into two categories; cortisone and injectable viscosupplementation. Cortisone injections have been around for decades and provide rapid but short term relief. They also exhibit side effects therefore should be used in moderation. In my practice, no more than once a quarter. Injectable viscosupplementation (“rooster shots”) are injections of a protein normally found in our joints and make a cushion to replace cartilage while improving the viscosity of joint fluid. These injections are performed in an office environment on a weekly basis for a period of 3-5 weeks.

Utilizing these recommendations will hopefully make your interaction with your orthopedic surgeon a social visit rather than professional.

 

 

 

Baby Teeth and Babies’ Teeth

 Baby Teeth and Babies’ Teeth

by Dr. Robert Stanaland

Baby teeth are so important! This cannot be stressed enough. Yes, they will be “lost” eventually, but they play a vital role in a child’s jaw development in addition to aiding in proper nutrition and socially.  Here are the answers to several questions we hear a lot.

When should I start brushing my baby’s teeth?

As soon as you are aware that any have erupted. Even before teeth come, you can be wiping down your baby’s mouth with a damp cloth after every feeding.

Why are baby teeth so important if they just fall out?

Obviously, children use their teeth to chew food, just like the adults. The baby teeth also act as place holders for the adult teeth, and if they are lost too soon, the adult teeth will have huge problems coming in correctly. Teeth that get decay can cause severe pain and infections. Children miss a lot of school in order to deal with dental problems, and the cost of treating these dental problems far outweighs the cost of preventing them. 

When should I take my child to the dentist?

It is recommended that a child be seen by age one (1) or within six (6) months of their first tooth erupting, but the child should have been in a dental office long before then. Expecting mothers should be seeing their dentist regularly before the child is here, so education begins then.

What else can I do for my kid’s teeth?

Take care of YOUR teeth! See a dentist regularly. If you have established good oral hygiene and diet habits, your children will too. “Bad teeth” are NOT inherited, but bad habits can be passed down to your children.

Dr. Robert Stanaland is a dentist at the Family Health Dental Clinic at
840 West Clements in Odessa, TX. (432) 332-8870

MEDICAL MATTERS: It’s blood pressure 102

MEDICAL MATTERS: It’s blood pressure 102

As seen in the Odessa American “Medical Matters”: http://www.oaoa.com/people/health/article_142b7e0e-eb15-11e6-8175-e70526b7ef79.html

by Dr. Fernando Boccalandro

In my first article I discussed the basics of blood pressure and the definition of normal blood pressures values according to current guidelines. In this second article I will address some practical tips and tricks, to maintain an adequate blood pressure control.

Blood pressure tends to fluctuate due to multiple factors that affect the blood pressure including stress, level of activity, salt intake, fluid intake, etc. For my patients the goal is to keep their average blood pressure within normal levels over time, rather than focus on one, or another individual blood pressure number specifically. Think about the average of the blood pressures as the number to go by.

What are my pearls of wisdom for our readers, after diagnosing and treating hundreds of patients with elevated blood pressure?

  1. Know your numbers:Make sure that you measure and know what your blood pressure is, at least once or twice a year if you do not have hypertension. It is useful to have an automated blood pressure machine at home, especially if you are prescribed blood pressure medications to assure is well controlled. Bring your blood pressure machine to your appointments; to make sure is well calibrated and you blood pressure measurements.
  1. Do your homework:Keeping a diet low in salt (less than 2 grams of sodium a day), a healthy weight, decrease levels of stress and regular moderate exercise (at least 150 minutes weekly), can contribute to lower your blood pressure and will make you feel better. Take your medications as prescribed and do not discontinue your blood pressure medications without discussing it first with your healthcare provider.
  1. Plan for the long term:Hypertension in the majority of patients is a chronic disease, like diabetes, high cholesterol, etc. So plan for a lifetime commitment to monitor and control your blood pressure, it is well worthwhile to prevent any adverse consequences of uncontrolled hypertension.
  1. Get the best team:Successful blood pressure management is teamwork. It is important to involve your family to help you succeed in this lifetime goal if you have elevated blood pressure. And it is very important to be in close contact with your health care professional, to coach and advise you regarding goals and optimization of your blood pressure levels over time.

Don’t let your guard down with high-blood pressure! And please contact your primary care doctor if you have questions or concerns about your heart health.

 

Prostate Cancer Awareness Month

Prostate Cancer Awareness Month
by Maria Scott, MCHS Community Health Nurse Navigator

September is Prostate Cancer Awareness Month. Please take a moment to learn a bit more about prostate cancer as well as the risks, screenings and treatments associated with it.

What is prostate cancer?

Prostate cancer is the most common cancer in men in the United States, after skin cancer. It is the second leading cause of death from cancer in men. Prostate cancer occurs more often in African-American men than in white men. African-American men with prostate cancer are more likely to die from the disease than white men with prostate cancer.

What is the prostate?

The prostate is a gland found only in males. It makes some of the fluid that is part of semen.

The location of the prostate is below the bladder and in front of the rectum. Because the size of the prostate changes with age, the walnut size found in younger men can be much larger in older men. 

What are the most common prostate problems?

Prostatitis is swelling and inflammation of the prostate gland, often causes painful or difficult urination. Although Prostatitis is more common in men over 50 years of age, it can affect men of all ages.

Benign Prostatic Hyperplasia, or BPH, is when the prostate is enlarged but not cancerous. It is very common in older men.

Prostate Cancer begins when cells in the prostate gland start to grow uncontrollably.

What are the risk factors?

Age – Prostate cancer is rare in men under the age of 40. The chance of a man having prostate cancer rises rapidly for men over the age of 50. About six of every ten prostate cancer cases are found in men older than 65.

Race/Ethnicity – Prostate cancer occurs more often in African-American men and in Caribbean men of African ancestry than in men of other races. African-American men are also more than twice as likely to die of prostate cancer as white men. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites.

Family History – The fact that Prostate Cancer seems to run in some families suggests that there may be an inherited or genetic factor in some cases. However, most prostate cancers occur in men without a family history of it.

Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease. (The risk is higher for men who have a brother with the disease than for those who have a father with it.) The risk is much higher for men with several affected relatives, particularly if their relatives were young when the cancer was found.

Can prostate cancer be prevented?

There is no sure way to prevent prostate cancer due to the fact that many risk factors such as age, race, and family history cannot controlled. Additionally, according with the American Cancer Society the effects of body weight, physical activity and diet on prostate cancer risk are not clear. However, in order to lower your risk of prostate cancer, the following things should be considered that might lower your risk:

  • Eating at least 2½ cups of a wide variety of vegetables and fruits each day.
  • Being physically active
  • Staying at a healthy weight

What tests can detect prostate cancer early?

Screening is testing to find cancer in people before they have symptoms. For some types of cancer, screening can help find cancers at an early stage, when they are likely to be easier to treat.

Prostate cancer can often be found before symptoms arise by testing the amount of prostate-specific antigen (PSA) in a man’s blood. Another way to find prostate cancer is the digital rectal exam (DRE), in which the doctor puts a gloved, lubricated finger into the rectum to feel the prostate gland.

At this time, the American Cancer Society (ACS) recommends that men thinking about getting screened for prostate cancer should make informed decisions based on available information, discussion with their doctor, and their own views on the possible benefits, risks and limits of prostate cancer screening.

The MCH 123 on Prostate Cancer

  1. One in seven men will be diagnosed with prostate cancer.
  2. Get a PSA test beginning at age 50.
  3. Early detention is the key!

Sources: America Cancer Society and National Cancer Institute