Pancreatic Cancer

Pancreatic Cancer (Symptoms,Causes and Treatment)

The pancreas, a gland in the belly that creates hormones like insulin and glucagon as well as digestive enzymes, is where pancreatic cancer typically develops. Due to its propensity for aggression and difficulty in being recognized in its early stages, it is one of the most deadly types of cancer. Adenocarcinomas, which begin in the cells that lining the pancreatic ducts, make up the majority of cases of pancreatic cancer. Smoking, being overweight, having chronic pancreatitis, diabetes, and a family history of the disease are all risk factors for developing pancreatic cancer. Abdominal pain, jaundice, unexplained weight loss, and digestive issues are possible symptoms. Depending on the stage of the malignancy, treatment options may include surgery, chemo, and radiation.

This article covers the following topics :

 

What does a pancreas do?

A glandular organ, the pancreas is situated in the belly, behind the stomach. It is a component of the endocrine and digestive systems. Digestive enzymes are secreted by the pancreas and aid in the small intestine’s breakdown of carbs, proteins, and lipids. Additionally, it creates hormones like glucagon and insulin that control how the body uses glucose.

Pancreatic cancer: What is it?

A kind of cancer called pancreatic cancer develops in the cells of the pancreas, a gland behind the stomach that makes hormones like insulin and glucagon as well as digesting enzymes. Pancreatic cancer is a dangerous condition that can spread quickly and is frequently discovered at an advanced stage, making treatment challenging.

Although the precise etiology of pancreatic cancer is unknown, a number of risk factors have been discovered, including smoking, obesity, chronic pancreatitis, a family history of the disease, and a few genetic disorders like Lynch syndrome and hereditary pancreatitis. Pancreatic cancer risk has also been linked to exposure to specific chemicals and carcinogens, such as benzene.

Early on, pancreatic cancer frequently exhibits minimal symptoms, making detection challenging. Abdominal or back pain, unexplained weight loss, jaundice (a yellowing of the skin and eyes), nausea, vomiting, and changes in bowel habits are all possible indications of cancer as it advances. Fatigue, appetite loss, and blood clots are some further signs that the disease may have progressed outside of the pancreas.

Imaging tests like computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and endoscopic ultrasonography (EUS) are frequently used to diagnose pancreatic cancer. Usually, a pancreatic tissue biopsy is necessary to establish the cancer’s stage and confirm the diagnosis.

Depending on the stage of the disease, a patient may have surgery to remove the tumor, chemotherapy, radiation therapy, or targeted therapy as a treatment option. A combination of these therapies may be applied in some situations. Additionally, palliative care may be given to help with symptom management and enhance quality of life.

Pancreatic cancer has a usually poor prognosis, with a 10% 5-year survival rate. This is partly because pancreatic cancer is frequently not discovered until it has already spread outside of the pancreas. Nevertheless, early detection and treatment can improve results, so it’s critical for those who are more at risk for pancreatic cancer to receive routine tests and for those who are experiencing symptoms to find a doctor as soon as possible.

What forms of pancreatic cancer are there?

Adenocarcinoma, which accounts for nearly 85% of all occurrences of pancreatic cancer, is the most prevalent kind. The pancreatic ducts, which are the tubes that transfer digestive enzymes from the pancreas to the small intestine, are where adenocarcinoma begins to develop. Pancreatic cancer can also occur in:

1-Pancreatic neuroendocrine tumors (PNETs): These are uncommon tumors that originate in the pancreatic hormone-producing cells. They may be cancerous or benign.

2-Acinar cell carcinoma: This uncommon form of pancreatic cancer develops from cells in the organ that make digestive enzymes.

3-Adenosquamous carcinoma: This uncommon form of pancreatic cancer combines elements of squamous cell carcinoma and adenocarcinoma.

4-Squamous cell carcinoma: This uncommon form of pancreatic cancer begins in the flat cells that line the pancreatic ducts.

5-Undifferentiated carcinoma: This uncommon form of pancreatic cancer lacks any distinguishing characteristics from other forms of the disease.

Pancreatoblastoma, a rare form of pancreatic cancer that typically affects youngsters under the age of 10, is the sixth type. It begins during fetal development in the cells that become the pancreas.

Depending on the type of cancer, there may be differences in the pancreatic cancer prognosis and treatment.

Who is prone to pancreatic cancer?

Although anyone can get pancreatic cancer, there are specific risk factors that make the disease more likely to occur. These consist of:

1-Age: Pancreatic cancer risk rises with age, with most instances being discovered in patients over 65.

2-Gender: Men are somewhat more likely than women to acquire pancreatic cancer.

3-Smoking: Smokers are up to three times more likely to acquire pancreatic cancer than non-smokers. Smoking is a significant risk factor for the disease.

4-Family history: Those who have a history of pancreatic cancer in their family are more likely to get the illness.

5-Inherited gene mutations: Pancreatic cancer risk can be raised by inherited gene mutations, such as those in the BRCA2 gene or Lynch syndrome.

6-Chronic pancreatitis: Pancreatic cancer risk may be increased by persistent pancreatic inflammation.

7-Diabetes: Pancreatic cancer is somewhat more likely to occur in those with long-term diabetes.

8-Obesity: Obesity has been associated with a higher chance of developing pancreatic cancer.

9-Diet: A diet that is heavy on processed and red meat and light on fresh produce may raise the risk of developing pancreatic cancer.

It is crucial to understand that a person’s presence of one or more of these risk factors does not guarantee that they will develop pancreatic cancer.

Which signs and symptoms accompany pancreatic cancer?

The location and size of the tumor might affect the pancreatic cancer symptoms in different ways. It might be challenging to diagnose pancreatic cancer in its early stages because it frequently exhibits no symptoms. The following signs and symptoms may appear as cancer spreads:

1-Abdominal discomfort or pain: This is frequently felt in the upper abdomen or back and may get worse after eating or lying down.

2-Jaundice: This skin and eye yellowing can happen when the tumor obstructs the bile duct, which transports bile from the liver to the small intestine.

3-Weight loss: Cancer-related changes in metabolism or a loss of appetite can lead to this.

4-Fatigue: This condition may be brought on by cancer or adjustments to the body’s metabolism.

5-Nausea and vomiting: This can happen if the tumor blocks the small intestine.

6-Changes in bowel habits: If the tumor obstructs the digestive tract, this can happen.

7-New-onset diabetes: This can happen when a tumor harms the insulin-producing cells in the pancreas.

It is crucial to keep in mind that these symptoms can also be brought on by other illnesses, making a visit to a doctor necessary for a correct diagnosis.

Why does pancreatic cancer develop?

Although the precise origin of pancreatic cancer is not entirely understood, a number of factors have been noted as potential contributors to the disease’s onset. Pancreatic cancer risk factors include some of the following:

1-Age: Pancreatic cancer risk rises with age, with the majority of cases being discovered in those over 60.

2-Gender: Men are slightly more likely than women to have pancreatic cancer.

3-Smoking: Pancreatic cancer is significantly increased by smoking. Compared to non-smokers, smokers have a two- to three-fold increased risk of developing pancreatic cancer.

4-Family history: Having a family history of pancreatic cancer or having specific genetic diseases (such BRCA2 mutations, Lynch syndrome, or familial atypical mole-malignant melanoma syndrome) may make you more likely to have the disease.

5-Chronic pancreatitis: Pancreatic inflammation that lasts for a prolonged period of time, or chronic pancreatitis, increases the risk of developing pancreatic cancer.

6-Diabetes: Although the precise link between the two conditions is unclear, those with diabetes have a higher risk of acquiring pancreatic cancer.

7-Obesity: Studies have shown a correlation between pancreatic cancer risk and being overweight or obese.

8-Heavy alcohol use: Long-term heavy alcohol use can raise the risk of pancreatic cancer.

9-Exposure to specific chemicals: Benzene and specific pesticides are two toxins that may raise the risk of developing pancreatic cancer.

The presence of one or more risk factors is not a guarantee that someone will get pancreatic cancer, and many people with the disease have no detectable risk markers.

What are the causes of pancreatic cancer risk factors?

There are several known risk factors that raise the possibility of getting pancreatic cancer, such as:

1-Age: People over 60 years old account for the majority of pancreatic cancer cases.

2-Smoking: Pancreatic cancer is significantly increased by smoking. Compared to non-smokers, smokers have a two- to three-fold increased risk of developing pancreatic cancer.

3-Obesity: Pancreatic cancer is one of the cancers for which obesity is a risk factor.

4-Diabetes: People who have had diabetes for a long time are more likely to get pancreatic cancer.

5-Chronic pancreatitis: Those who experience chronic pancreatic inflammation (pancreatitis) are more likely to get pancreatic cancer.

6-Family history: Your risk of acquiring pancreatic cancer increases if you have a first-degree relative (parent, sibling, or kid) who has the disease.

7-Inherited genetic syndromes: Variations in the BRCA1 and BRCA2 genes, for example, can raise the risk of developing pancreatic cancer.

8-Race: African Americans are more likely than whites to have pancreatic cancer.

9-Gender: Men have a somewhat higher risk of developing pancreatic cancer than women do.

It’s crucial to remember that despite the fact that many people who have pancreatic cancer have no known risk factors, having one or more risk factors does not guarantee that you will get the disease.

Do female pancreatic cancer symptoms differ from male pancreatic cancer symptoms?

Males and females experience pancreatic cancer symptoms similarly, with no discernible differences. The signs of pancreatic cancer, which might include jaundice, abdominal pain, unexplained weight loss, and digestive issues, are typically the same for both sexes. Though the reasons for this are not totally obvious, some research indicate that females may have a slightly higher survival rate than males. Remember that pancreatic cancer is a relatively uncommon form of the disease, and seek medical attention right away if any alarming symptoms appear.

The method for detecting pancreatic cancer.

Early detection of pancreatic cancer can be challenging since symptoms may not appear until the cancer has grown and spread outside of the pancreas. Based on your symptoms, medical history, and physical examination, your healthcare practitioner may request a number of tests to identify pancreatic cancer, including:

1-Blood tests may be prescribed by your doctor to screen for particular pancreatic enzymes and other substances that could be signs of pancreatic cancer.

2-Imaging procedures: The pancreas and its surrounding tissues can be seen using imaging procedures like CT scans, MRIs, or ultrasounds to look for tumors and determine whether cancer has spread.

3-Endoscopic ultrasonography (EUS): To visualize the pancreas and surrounding tissues, an endoscope and an ultrasound probe are inserted through the mouth, into the stomach, and small intestine.

4-Biopsy: A biopsy is the excision of a tiny sample of pancreatic tissue for microscopic examination. The biopsy can be carried out either during an endoscopy or with a small needle inserted via the skin.

5-Laparoscopy: Laparoscopy is a medical procedure that entails making a few tiny incisions in the abdomen to introduce a small camera and other devices to view the pancreas and surrounding tissues.

A pathologist who examines the biopsy sample under a microscope confirms the pancreatic cancer diagnosis.

How far along is pancreatic cancer?

The process of staging pancreatic cancer involves figuring out how far the disease has gone throughout the organ and its surroundings. Doctors use the pancreatic cancer patient’s stage to assist them choose the most effective course of treatment. The size of the tumor, the extent to which it has penetrated the pancreas and adjacent organs, and whether or not it has spread to lymph nodes or other parts of the body all play a role in determining the stage of pancreatic cancer.

The TNM staging system, which stands for Tumor, Nodes, and Metastasis, is the one that is most frequently used for pancreatic cancer. With the help of this approach, it is possible to determine the size and scope of the main tumor (T), whether the cancer has spread to surrounding lymph nodes (N), and whether it has reached other body regions (M). Using this information, four stages—stage I, stage II, stage III, and stage IV—of pancreatic cancer are commonly identified.

1-Stage I: At this point, the cancer has not spread to the lymph nodes or other organs in the area and is still restricted to the pancreas. The pancreas houses the tumor, which is normally smaller than 2 cm in size.

2-Stage II: At this stage, the pancreas is no longer the only organ affected by the disease, and it may have progressed to neighboring lymph nodes, but it has not yet migrated to other regions of the body. In addition to potentially involving surrounding blood arteries or organs including the duodenum, bile duct, or stomach, the tumor may be larger than 2 cm.

3-Stage III: At this stage, the cancer has metastasized to surrounding lymph nodes, blood arteries, or organs such the colon, spleen, or stomach. Although the tumor has not yet spread to distant regions of the body, it may be of any size and have already invaded neighboring organs.

4-Stage IV: At this point, the cancer has spread to distant organs including the liver, lungs, or bones. Any size tumors are possible, and they may have already penetrated surrounding blood arteries or organs.

The American Joint Committee on Cancer (AJCC) TNM staging system, which is comparable to the TNM method previously mentioned but offers more specific information on tumor size, lymph node involvement, and distant metastases, is another staging approach used for pancreatic cancer. The overall stage of pancreatic cancer, which ranges from stage 0 to stage IV, is determined using the AJCC system.

In general, stage I and stage II pancreatic cancer are more likely to be surgically treatable, whereas stage III and stage IV pancreatic cancer may need a combination of surgery, chemotherapy, and radiation therapy to control symptoms and reduce the disease’s growth.

The way that pancreatic cancer is handled.

The patient’s general health and the cancer’s stage will both influence the course of treatment for pancreatic cancer. The sole curative treatment for pancreatic cancer is surgery, but this is not always an option due to the disease’s severe stage at diagnosis or the patient’s health. Chemotherapy, radiation therapy, targeted therapy, immunotherapy, and palliative care are other treatment possibilities.

1-Surgery: The only curative therapy for pancreatic cancer is surgery. It entails the excision of the tumor as well as, sporadically, pieces of the duodenum, pancreas, and adjacent lymph nodes. Only if the cancer is confined and has not spread to other bodily parts is surgery an option. The location and size of the tumor determine the type of surgery. The two most typical procedures used to treat pancreatic cancer are:

The head of the pancreas, the duodenum, a piece of the stomach, the gallbladder, and adjacent lymph nodes are all removed during the Whipple procedure. The head of the pancreatic tumors are treated with this surgery.

*Distal pancreatectomy: The body and tail of the pancreas, as well as occasionally the spleen, are removed during this treatment. Tumors in the body and tail of the pancreas are treated with this surgery.

2-Chemotherapy: This treatment employs chemicals to destroy cancer cells. Advanced pancreatic cancer patients may receive it as their main course of treatment, before or after surgery. Chemotherapy medications can be administered orally or intravenously. Gemcitabine, 5-fluorouracil (5-FU), nab-paclitaxel, and oxaliplatin are frequently used chemotherapeutic agents for pancreatic cancer. Chemotherapy side effects might include dizziness, nausea, hair loss, exhaustion, and an elevated risk of infection.

3-Radiation therapy: High-energy X-rays are used in radiation therapy to eliminate cancer cells. It can be used as a main treatment for locally advanced pancreatic cancer, either before or after surgery. Additionally, radiation therapy and chemotherapy are interchangeable. Skin irritation, nausea, vomiting, and exhaustion are a few of the adverse reactions that radiation therapy may produce.

4-Targeted therapy: Drugs that specifically target proteins or genes that promote the growth of cancer cells are used in targeted therapy. Drugs for targeted therapy might be administered orally or intravenously. Erlotinib and sunitinib are two popular medications used in pancreatic cancer targeted therapy. The negative effects of targeted therapy can include skin rashes, diarrhea, exhaustion, and an elevated risk of infection.

5-Immunotherapy: Immunotherapy employs medicines that support the immune system’s ability to identify and combat cancer cells. Drugs for immunotherapy might be administered orally or intravenously. Pembrolizumab and nivolumab are typical pancreatic cancer immunotherapy medications. Fatigue, rashes, and a higher risk of infection are a some of the negative effects that immunotherapy may bring on.

6-Palliative care: For those with advanced pancreatic cancer, palliative care focuses on symptom relief and enhancing quality of life. A group of medical experts, including doctors, nurses, social workers, and spiritual counselors, can offer palliative care. Palliative care can offer patients and their families emotional support while managing symptoms including pain, nausea, and tiredness.

Patients with pancreatic cancer may receive a mix of therapies, like surgery followed by chemotherapy and radiation therapy. Based on the cancer stage, the patient’s general health, and the therapy objectives, a unique treatment plan is created for each patient.

What additional information regarding the therapy do you require?

Regarding the management of pancreatic cancer, there are a number of other factors to take into account. Following are some key considerations:

1-Multidisciplinary approach: The treatment of pancreatic cancer frequently necessitates a multidisciplinary strategy, comprising experts from several domains such surgery, medical oncology, radiation oncology, gastroenterology, and interventional radiology.

2-Pain management: Effective pain management is a crucial component of pancreatic cancer treatment because pain can be a serious issue for those who have it. This could entail using drugs, nerve blocks, or other treatments.

3-Nutritional assistance: People with pancreatic cancer may have trouble chewing and digesting food, therefore they may require assistance with nourishment through intravenous or tube feeding.

4-Palliative care is a type of medical care that focuses on enhancing the quality of life for patients with life-threatening illnesses and can play a significant role in the treatment of pancreatic cancer. Symptom management, emotional support, and spiritual care are all possible components of palliative care.

5-Clinical trials: Research studies that evaluate brand-new pancreatic cancer therapies are known as clinical trials. Some people with pancreatic cancer may choose to take part in a clinical trial, which can give them access to cutting-edge therapies.

6-Emotional help: Pancreatic cancer can be a challenging diagnosis to handle, so it’s crucial for patients and their loved ones to receive emotional support. Counseling, support groups, or other tools might be used in this.

Overall, treating pancreatic cancer involves an all-encompassing strategy that takes into account the disease’s practical, emotional, and physical obstacles in addition to the cancer itself.

Where does pancreatic cancer tend to progress the most?

The liver, gallbladder, stomach, spleen, and intestines are a few examples of neighboring organs and tissues where pancreatic cancer can metastasis (spread). It can also spread to distant organs including the lungs and bones as well as lymph nodes close to the pancreas. In the later stages of the illness, the sickness spreads to distant organs.

Is there a cure for pancreatic cancer?

The likelihood of a cure for pancreatic cancer depends on a number of variables, including the tumour’s stage and the patient’s general condition. Pancreatic cancer is often most treatable when it is discovered early, before it has spread to other body areas. However, it can be challenging to detect pancreatic cancer early because it sometimes does not show symptoms until it is more advanced.

The only possibly curative treatment for pancreatic cancer is surgery to remove the tumor. Surgery is only a possibility, though, if the cancer has not advanced past the pancreas and the patient is in good enough health to have the treatment. Treatments like chemotherapy, radiation therapy, and targeted therapy may help decrease the tumor and ease symptoms in people with advanced pancreatic cancer, but they do not cure the disease.

The fact that every person’s circumstances are unique and that there is no one-size-fits-all method of treating pancreatic cancer should be emphasized. A individualized treatment plan based on the individual’s unique circumstances can be created by a multidisciplinary team of healthcare professionals, including medical oncologists, radiation oncologists, surgical oncologists, gastroenterologists, and supportive care specialists.

How may pancreatic cancer be avoided?

Although there is no guaranteed strategy to avoid acquiring pancreatic cancer, there are a number of steps that can be taken to reduce the risk. Among the approaches to stop pancreatic cancer are:

1-Stop smoking: The single biggest risk factor for pancreatic cancer is smoking. You can dramatically lower your risk of acquiring pancreatic cancer by giving up smoking.

2-Maintaining a healthy weight: Pancreatic cancer risk is higher in people who are overweight or obese. You may maintain a healthy weight by eating a balanced diet and exercising frequently.

3-Limiting alcohol intake: Excessive alcohol use has been associated with a higher risk of pancreatic cancer. One drink for ladies per day and two for males is the maximum amount that should be consumed to lower this risk.

4-Eating a nutritious diet: Eating a diet full of fresh produce, whole grains, and lean proteins may help lower the risk of pancreatic cancer. Red and processed meats should also be consumed in moderation as they have been associated with an elevated risk of pancreatic cancer.

5-Diabetes management: Diabetes has been associated with a higher risk of pancreatic cancer. Working with your healthcare practitioner to control your blood sugar levels is crucial if you have diabetes.

6-Getting routine checkups: It’s crucial to talk to your healthcare provider about routine screening if you have a family history of pancreatic cancer or other risk factors. Regular checkups can aid in the early detection of pancreatic cancer, while it is still the most curable.

7-Genetic testing: Some persons may have a genetic mutation that puts them at a higher risk of getting pancreatic cancer. It may be beneficial to undertake genetic testing to ascertain whether you have an elevated risk if there is a family history of pancreatic cancer.

It’s crucial to remember that while taking these precautions can help lower the risk of pancreatic cancer, they cannot ensure protection. Even with these precautions, some people may still acquire pancreatic cancer.

How long will someone with pancreatic cancer live?

The stage of the cancer, general health, and response to treatment are just a few of the variables that affect a person’s life expectancy after being diagnosed with pancreatic cancer. The overall five-year survival rate for pancreatic cancer is roughly 10%, according to the American Cancer Society, with many cases of the disease being discovered at an advanced stage when it has already migrated outside of the pancreas. The five-year survival rate for pancreatic cancer is substantially greater, at about 37%, if it is discovered early while it is still localized. It’s crucial to remember that survival statistics are simply estimations and might not correspond to a specific person’s experience. It is best to talk with a healthcare provider about the prognosis and available treatments.

What percentage of stage 4 pancreatic cancer patients survive?

Stage 4 pancreatic cancer has a generally poor prognosis for survival. When pancreatic cancer is in its fourth stage, it has migrated to distant organs including the liver, lungs, or abdominal cavity.

All pancreatic cancer stages have a 5-year survival rate of roughly 10% overall, but stage 4 pancreatic cancer has a substantially lower 5-year survival rate, usually less than 3%.

It’s crucial to remember that survival rates are merely statistics and that each person’s prognosis might change based on things like age, general health, treatment response, and the kind and degree of their cancer.

While receiving a stage 4 pancreatic cancer diagnosis can be challenging, it’s crucial to collaborate closely with a healthcare team to create a treatment strategy that is tailored to the patient’s particular needs. To treat symptoms and maximize life span, this may require a mix of chemotherapy, radiation therapy, and/or surgery. Palliative care can also offer assistance in managing symptoms and enhancing quality of life.

When should I schedule a consultation with my doctor concerning pancreatic cancer?

It is crucial to see your doctor if you experience any pancreatic cancer symptoms or have any risk factors. The following are some signs of pancreatic cancer:

*Jaundice (a skin and eye yellowing)

*Back or abdominal pain

*Unaccounted for weight loss

*Decreased appetite

*Vomiting and nauseous

*Variations in stool color

*Diabetes with new onset

*Fatigue

In order to identify the underlying cause, it is crucial to talk to your healthcare professional because similar symptoms might also be brought on by other disorders.

Additionally, you should talk with your healthcare practitioner about screening alternatives if you have a family history of pancreatic cancer or other risk factors like smoking, obesity, or a history of chronic pancreatitis. Early detection can increase the likelihood of effective therapy and a better result.

What inquiries should I make of my doctor regarding pancreatic cancer?

Finding the right questions to ask your doctor might be challenging if you or a loved one has been diagnosed with pancreatic cancer. Here are some queries to think about:

1-How can I know what kind of pancreatic cancer I have?

2-How far along is my cancer?

3-What are my available therapy options, and which do you suggest?

4-What could the recommended treatment(s) have as side effects?

5-Am I potentially eligible for any clinical trials?

6-How long will my treatment persist and what effects can I expect in my day-to-day activities?

7-What results should I anticipate from my treatment?

8-Which options for help are accessible to me and my family at this time?

9-How can I alter my lifestyle to enhance my general health and wellbeing?

10-Are there any particular examinations or monitoring that must be carried out following treatment?

Never forget to bring up any queries or worries you may have with regard to your diagnosis, course of treatment, or outlook with your healthcare professional. They are available to give you the advice and assistance you require as you go through this trying period.

What services are offered to those who have pancreatic cancer?

For those who have pancreatic cancer and their families, there are a number of resources accessible, including:

1-Pancreatic Cancer Action Network: This group offers support groups, resources for patients and families, and information about pancreatic cancer.

2-Lustgarten Foundation: The Lustgarten Foundation supports research into pancreatic cancer and offers assistance to patients’ families.

3-American Cancer Society: The American Cancer Society offers support groups, tools for patients and families, and information on pancreatic cancer.

4-National Cancer Institute: The National Cancer Institute offers data on pancreatic cancer, research, and clinical trials.

5-CancerCare: For persons with pancreatic cancer and their families, CancerCare offers free support services like counseling, support groups, financial aid, and education.

6-Hospice and palliative care initiatives: These initiatives give pancreatic cancer patients and their families end-of-life care and support.

Local support groups for those with pancreatic cancer and their families are available in many communities. These organizations offer resources, knowledge, and emotional support.

According to your unique needs and circumstances, it’s crucial to discuss which resources can be beneficial for you with your healthcare physician.