The vulva is the external portion of the female reproductive system. The vulva includes two prominent skin folds known as the labia majora, and two more delicate, barely visible, hairless skin folds called the labia minora. These inner and outer labia (Latin for lips) meet, protecting the vaginal vestibule (the space where the vagina opens) and, just above it, the opening of the urethra (the short tube that connects to the bladder). At the front of the vestibule, the labia minora meet to form a fold or small hood of skin called the prepuce. Beneath it lies the clitoris, an approximately 3/4 inch structure of highly sensitive tissue that becomes swollen with blood during sexual stimulation. At the opposite end of the vestibule, just beneath the vaginal opening, is the fourchette, where the labia minora meet. Beyond the fourchette is the anus, the opening to the rectum. The space between the vagina and the anus is called the perineum.
Cancer of the vulva (also known as vulvar cancer) is a malignancy that can occur on any part of the female external reproductive system but most often affects the inner edges of the labia majora or the labia minora. Less often, cancer occurs on the clitoris or in Bartholin glands (small mucus-producing glands on either side of the vaginal opening).
Over 90% of cancers of the vulva are squamous cell carcinomas, which means they begin in squamous cells, the main cell type of the skin. This type of cancer usually forms slowly over many years, and is usually preceded by precancerous changes that may last for several years. The medical term most often used for this precancerous condition is vulvar intraepithelial neoplasia, or VIN. "Intraepithelial" means that the precancerous cells are confined to the epithelium (surface layer of the vulvar skin). VIN is often divided into three categories - VIN1, VIN2, and VIN3, with the last indicating furthest progression toward a true cancer. Dysplasia is often used as another term for VIN. Using this terminology there is also a spectrum of increasing progress toward cancer: first mild dysplasia; next moderate dysplasia; then severe dysplasia; and finally, carcinoma in situ. Not all women with VIN or dysplasia will develop vulvar cancer. However, it is not possible to predict which women will, so treatment is very important and is discussed under Can Vulvar Cancer Be Prevented? In the past, cases of VIN were included under the broad category of disorders known as vulvar dystrophy. Since this category included a wide variety of other diseases, most of which are not precancerous, most doctors no longer use this term.
The second most common type of vulvar cancer (about 4%) is melanoma. Melanomas develop from the pigment-producing cells that determine the skin's color. This disease is discussed in greater detail in an American Cancer Society document called Melanoma Skin Cancer. About 5% to 8% of melanomas in women occur on the vulva, usually on the labia minora and clitoris.
A small percentage of vulvar cancers develop from glands and are called adenocarcinomas. Some develop from Bartholins glands, which are found at the opening of the vagina and which produce a mucus-like lubricating fluid. Although most Bartholin gland cancers are usually adenocarcinomas; some (particularly those developing from the gland ducts) may be different types, either transitional cell carcinomas or squamous cell carcinomas. Adenocarcinomas can also form in the sweat glands of the vulvar skin, although this is quite rare.
Paget's disease of the vulva is a condition in which adenocarcinoma cells are found in the vulvar skin. Between 20% and 25% of patients with vulvar Paget's disease also have an invasive adenocarcinoma of a Bartholin gland or sweat gland. In the remaining 75% to 80%, the malignant cells are found only in the skin's top layer and do not involve the tissues under that layer. Since a tumor in the Bartholin gland is easily mistaken for a cyst (accumulation of fluid in the gland), delay in accurate diagnosis is common.
Less than 2% of vulvar cancers are sarcomas, tumors of the connective tissues under the skin that tend to grow rapidly. Unlike other cancers of the vulva, vulvar sarcomas can occur at any age, including in childhood.
Verrucous carcinoma resembles a large wart and requires a biopsy to distinguish it from that benign growth. This form of vulvar cancer is a slow-growing subtype of squamous cell carcinoma and tends to have a good prognosis (outcome).
Basal cell carcinoma, the most common cancer of sun-exposed areas of the skin, occurs very rarely on the vulva. It is discussed further in an American Cancer Society document called Non-Melanoma Skin Cancer.
WHAT ARE THE KEY STATISTICS ABOUT CANCER OF THE VULVA?
In the United States, vulvar cancer accounts for 4% of all cancers of the female reproductive organs, and 1/2% of all cancers in women.
The American Cancer Society estimates that during 1998, about 3,200 cancers of the vulva will be diagnosed in the United States. About 800 deaths due to vulvar cancer are expected during 1998.
When vulvar cancer is detected early, it is highly curable. The overall 5-year survival rate when the lymph nodes are not involved is 90%. The overall 5-year survival rate drops to 50% to 60% when cancer has spread to the lymph nodes.
DO WE KNOW WHAT CAUSES CANCER OF THE VULVA?
Several risk factors for cancer of the vulva are known, and we are beginning to understand how these factors can cause cells in the vulva to become cancerous.
Researchers have made great progress in understanding how certain changes in DNA can cause normal cells to become cancerous. DNA is the chemical that carries the instructions for nearly everything our cells do. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than our outward appearance. Some genes (parts of our DNA) contain instructions for controlling when our cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes. It is known that cancers can be caused by DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes. Usually DNA mutations related to cancers of the vulva occur during life rather than having been inherited before birth. Acquired mutations may result from cancer-causing chemicals in tobacco smoke. Sometimes they occur for no apparent reason.
Recent studies suggest that squamous cell vulvar cancer (the most common type) can develop in at least 2 ways. In about 1/3 to 1/2 of cases, HPV infection appears to have an important role. Two proteins (E6 and E7) produced by high-risk HPV types can interfere with the functioning of known tumor suppressor gene products (called p53 and Rb). This results in increased cell growth and in failure of cells to die when they become damaged. Vulvar cancers associated with HPV infection seem to have certain distinctive features. Women with these cancers often have multiple areas of VIN elsewhere on their vulvas, are usually smokers, and tend to be younger (35 to 55) than typical vulvar cancer patients.
The second process by which vulvar cancers develop does not involve HPV infection. Vulvar cancers not associated with HPV infection usually are diagnosed in older women (55 to 85) who rarely have VIN but often have lichen scerlosus. Tests of the DNA from vulvar cancers of older women not infected by HPV often show mutations of the p53 tumor suppressor gene. Younger patients with HPV infection and vulvar cancer rarely have p53 mutations. In these cases, the p53 in vulvar cells seems to be disabled by becoming associated with HPV proteins.
These recent discoveries have not yet had any impact on treatment. But, in the future, they will probably be important in developing prevention strategies and in selecting treatment strategies most appropriate for distinct older and younger squamous cell vulvar cancer patients.
Because of their rarity, much less is known about how vulvar melanomas and adenocarcinomas develop.
CAN CANCER OF THE VULVA BE FOUND EARLY?
Yes, by having pelvic examinations and being alert to any signs and symptoms of vulvar cancer. Early detection greatly improves the chances of successful treatment.
Signs and symptoms of vulvar intraepithelial neoplasia (VIN)
The most common symptom of VIN is persistent itching that does not improve. Areas of VIN usually have skin that is thicker and lighter in color than the surrounding skin. However, some cases of VIN can appear red, pink, or darker than the surrounding skin.
Because these symptoms can be caused by other conditions that are not precancerous, some women fail to recognize the seriousness of their condition and attempt to treat the problem themselves with over-the-counter remedies. Sometimes, even, doctors may not recognize the condition initially.
Signs and symptoms of invasive vulvar squamous cell cancer of the vulva
The signs and symptoms of early invasive vulvar cancer are similar to those of VIN. As invasion and growth progress, a distinct tumor is more likely to be recognized. The most common symptoms are a red, pink, or white bump or bumps with a wart-like and/or raw surface. An area of the vulva may appear white and feel rough. About half of the women with vulvar cancer complain of persistent itching and a growth in the genitalia. Some also complain of pain, burning, painful urination, bleeding, and discharge not associated with the normal menstrual period. An ulcer that persists for more than a month is another sign.
Signs and symptoms of other types of vulvar cancers
Vulvar melanoma: The appearance of a darkly pigmented lesion or a change in a mole that has been present for years may indicate melanoma. The ABCD rule can help tell a normal mole from one that could be melanoma.
- Asymmetry: One-half of the mole does not match the other.
- Border irregularity: The edges of the mole are ragged or notched.
- Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black, and sometimes patches of red, blue, or white.
- Diameter: The mole is wider than 6 millimeters (about 1/4 inch).
The most important sign of melanoma is a change in size, shape, or color or a mole. Some melanoma, however, do not fit the ABCD rule.
Bartholin gland cancer: A distinct mass on either side of the opening to the vagina may indicate a Bartholin gland carcinoma. However, similar symptoms may be due to a Bartholin's gland cyst which is much more common.
Paget's disease: Soreness and a red, scaly area are symptoms of Paget's disease of the vulva.
Verrucous carcinoma: One subtype of invasive squamous cell vulvar cancer with a particularly good prognosis, verrucous carcinoma appears as cauliflower-like growths similar to warts.
Knowing what to look for can sometimes helps with early detection, but it is even better not to wait until you notice symptoms. Have a regular Pap test and pelvic examination.
HOW IS CANCER OF THE VULVA TREATED?
Options for treating a patient with vulvar cancer depend on the stage of her disease. The stage of a cancer describes its size, depth of invasion and how far it has spread.
After the stage of your vulvar cancer has been established, your cancer care team will recommend a treatment strategy. Consider the options without feeling rushed. If there is anything you do not understand, ask for explanations. While the choice of treatment depends largely on the stage of the disease at the time of diagnosis, other factors include your age, your general health, your individual circumstances, and your preferences. Be sure you understand all the risks and side effects of the various therapies before making a decision.
You may want to seek a second opinion for personal or practical reasons. On the personal level, getting a second medical perspective can deepen your understanding of your treatment options and help you decide whether to work with your initial medical team or with those proposing a second view. On the practical side, some insurance companies require a second opinion before authorizing payment for your cancer care expenses.
The three main types of treatment used for patients with vulvar cancer are surgery, radiation therapy, and chemotherapy.
Types of surgery for cancer of the vulva
Choosing the best surgical treatment for each patient involves balancing the importance of maintaining a woman's sexual functioning with the need to remove all the cancer. In the past, surgeons removed a large amount of surrounding normal tissue and regional lymph nodes, regardless of the stage of the disease, because they wanted to be certain that no undetected stray cancer cells remained. Although such extensive surgery resulted in a good chance of cure, there were risks associated with the surgery: disfigurement resulted and the woman's ability to function sexually was impaired, if the clitoris was removed. Today, the importance of sexuality to a woman's quality of life is well recognized. It has also been established that, when cancer is detected early, it's not necessary to remove so much surrounding healthy tissue in order to achieve a cure. When cancer is more advanced a more radical procedure may be necessary. Radiation may be combined with surgery to kill more cancer cells in advanced cases.
The following types of surgery are listed in order of how much tissue is removed.
Laser surgery: A focused laser beam vaporizes (burns off) the layer of vulvar skin containing abnormal cells. Laser surgery is used as a treatment for VIN (preinvasive vulvar cancer). It is not used to treat invasive cancer.
Excision: The cancer and a margin of normal-appearing skin (usually about ½ inch) around it is excised. This is sometimes called wide local excision (if extensive, it may be called a simple partial vulvectomy).
Vulvectomy: There are several operations in which part or all of the vulva is removed. A skinning vulvectomy means only the top layer of skin affected by the cancer is removed. Although this is an option for treating extensive VIN3, this operation is rarely done. A simple vulvectomy removes the entire vulva. A radical vulvectomy can be complete or partial. When a part of the vulva, including the deep tissue, is removed, the operation is called a partial vulvectomy. A complete radical with vulvectomy removes the entire vulva and deep tissues, including the clitoris. An operation to remove the lymph nodes near the vulva is called a groin dissection.
If these procedures are used to remove a large area of skin from the vulva, skin grafts from other parts of the body may be needed to cover the wound. However, these procedures can usually be closed without grafts and provide a very satisfactory appearance. If a graft is required, the gynecologist oncologist may perform the surgery and consult with a plastic or reconstructive surgeon. The more tissue that is removed, the greater the risk of significant complications. Removal of wide areas of vulvar skin may result in failure of the wound to heal, failure of the skin graft to take, or wound infections.
Removal of lymph nodes during a radical vulvectomy can cause poor fluid drainage from the legs, causing fluid retention, prominent swelling, and increased risk of infections. This rare complication, called lymphedema, often is helped by support stockings or special compression devices. Women with lymphedema should also take precautions to avoid infections of the affected leg or legs. They should carefully protect the leg and foot from sharp objects and care of any cuts, scratches, or burns without delay. They should avoid sunburn of the affected leg and should not cut or tear cuticles of the toenails. Any redness, swelling or other signs of infection should be reported to the nurse or doctor without delay.
Other complications include formation of fluid-filled cysts near the surgical wounds, blood clots that may travel to the lungs, urinary infections, and reduction of sexual desire or pleasure.
Radiation therapy uses high energy x-rays to kill cancer cells. In treating vulvar cancers, these x-rays are delivered from outside the body in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation therapy.
The skin in the treated area may look and feel sunburned, but this gradually fades into a tanned look, returning to a normal appearance in six to 12 months. When delivered to the pelvis, premature menopause and problems with urination may also occur. If you have side effects from radiation, discuss them with your cancer care team. There are often treatments to obtain relief from these symptoms.
Chemotherapy uses anticancer drugs that are usually given intravenously (into a vein), by mouth, or applied to the skin in an ointment. Drugs taken by mouth or injected into a vein (called systemic chemotherapy) enter the bloodstream to reach all areas of the body, making this treatment potentially useful for cancer that has spread beyond the vulva. If this treatment is chosen, a combination of drugs may be given because combination chemotherapy is sometimes more effective than just one drug alone. Drugs most often used in treating vulvar cancer include cisplatin, mitomycin, fluorouracil (5-FU). Vulvar cancers that have spread to other organs tend to be resistant to chemotherapy. The role of chemotherapy in treating vulvar cancer remains to be determined. In extensive disease, chemotherapy may be combined with radiation therapy. This combined treatment may make future surgery less radical because it shrinks the tumor.
Side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of time you are treated. They include:
- Nausea and vomiting (new medications given with the chemotherapy can reduce or prevent these unpleasant side effects)
- Loss or increase of appetite
- Temporary loss of hair
- Mouth or vaginal sores
- Increased chance of infections due to low white blood cell counts, bleeding due to low blood platelet counts or tiredness due to anemia (low red blood cell counts)
- Changes in the menstrual cycle
- Premature menopause and infertility (inability to become pregnant) )(Note: most women with vulvar cancer are post-menopausal.)
Most of these side effects of chemotherapy stop when the treatment is over. If you are taking chemotherapy and have side effects, there are remedies for many of them. Be sure to talk with your cancer care team about any side effects you are experiencing.
Sometimes 5-fluorouracil (5-FU) is applied as a cream directly to the skin. This is called topical chemotherapy and is rarely used for VIN but not for invasive cancer of the vulva. Chemotherapy applied directly to the skin in ointment form will cause local irritation and peeling. This is normal and is part of the local destruction of cancer cells. Usually medicated ointments suggested by the health care team can help relieve the discomfort of this treatment. Topical chemotherapy for VIN is less effective than laser treatment or surgery.
To learn whether a new type of treatment is effective, scientists conduct studies following strict rules. The main questions they want to answer are:
- Does this new type of treatment work?
- Does it work better than other treatments already available?
- What side effects does the treatment cause?
- Do the benefits outweigh the risks, including side effects?
- In which patients is the treatment most likely to be helpful?
Studies of promising new or experimental treatments in patients are known as clinical trials. During a course of treatment for vulvar cancer, the doctor may suggest that you take part in a clinical trial of an investigational treatment. A clinical trial is only done when there is some reason to believe that the treatment being studied may be of value to the patient. Treatments used in clinical trials are often found to provide real benefits.
However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects will disappear in time, some can be permanent or even life-threatening. Keep in mind, though, that even standard treatments have side effects and that the disease you have can reduce the length or quality of your life. Depending on many factors, you may decide that a clinical trial will be of value in your case.
Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the trial begins, you are free to leave the study any time you want, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.
To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:
- What is the purpose of the study?
- What kinds of tests and treatments does the study involve?
- What does this treatment do?
- What is likely to happen in my case with, or without, this new research treatment?
- What are my other choices and their advantages and disadvantages?
- How could the study affect my daily life?
- What side effects can I expect from the study? Can the side effects be controlled?
- How long will the study last?
- Will I have to be hospitalized? If so, how often and for how long?
- Will the study cost me anything? Will any of the treatment be free?
- If I am harmed as a result of the research, what treatment would I be entitled to?
- What type of long-term follow-up care is part of the study?
You can get a list of current trials by calling the National Cancer Institute's Cancer Information Service toll free at 1-800-4-CANCER.
Treatment options for squamous cell vulvar cancer by stage
The stage of a vulvar cancer is the most important factor in choosing treatment. However, other factors that affect this decision include the exact location of the cancer on the vulva, the type of cancer, your age, and your overall condition.
Stage 0 (carcinoma in situ): Treatment options are the same for carcinoma in situ and for less advanced precancerous changes (vulvar intraepithelial neoplasia or VIN) . Laser surgery, wide local excision, or a skinning vulvectomy may be used, depending on the size and location of the cancer. 5-FU ointment may be prescribed. Stage 0 cancers may recur (come back) or new stage 0 cancers may form on other areas of the vulva. The 5-year survival rate approaches 100%, like pre-invasive skin cancers in other body sites.
Stage I: Treatment options depend on the size and depth of the cancer and whether the patient also has VIN. If the depth of invasion is 1 mm or less, Stage IA, and there are no other areas of cancer or VIN, an excisional biopsy that incorporates a 1 cm normal tissue margin is done. For more deeply invasive and larger Stage I cancers, Stage IB, a partial radical vulvectomy is necessary along with removal of nearby lymph nodes in the groin, (superficial and deep), on the same side as the cancer. Another option is a complete radical vulvectomy and removal of the groin lymph nodes, if the cancer is larger and quite extensive. For those who choose not to have their lymph nodes removed or who are not healthy enough to withstand the surgery, radiation therapy may be used instead of the lymph node dissection.
Stage II: The treatment for most Stage II vulvar cancer is partial radical vulvectomy and removal of the lymph nodes in the groin on both sides.
Stage III: Some of these bulky cancers can be cured by radical operations. A radical vulvectomy with removal of the lymph nodes in the groin (superficial and deep) may be successful in completely removing the tumor. However, most recent therapeutic efforts have focused on combined modality treatments and radiation therapy followed by surgery may be an option. Tests are underway to evaluate the use of radiation therapy, and/or systemic chemotherapy with 5-FU or cisplatin, followed by surgery in cases with a good response to chemotherapy or radiation.
Stage IV: The extent of the surgery beyond a radical vulvectomy depends on what organs contain cancer cells. Pelvic exenteration includes vulvectomy and removal of the pelvic lymph nodes and one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina. Radiation therapy may be done before or after surgery. Chemotherapy may also be given prior to followup surgery. In some cases where surgery is not advised, radiation and possibly chemotherapy are options.
Recurrent vulvar cancer: This means that the disease has recurred (come back) after treatment. Treatment options will depend on how soon the recurrence happens, its extent, and whether it is local (in the vulva), regional (in nearby lymph nodes), or distant (cancer has spread through the bloodstream to organs such as the lungs or bone). If it is local, it may still be possible to remove the cancer surgically, or by using combinations of chemotherapy, radiation therapy and surgery. When local recurrence occurs more than 2 years after the initial treatment, the prognosis is better than if the cancer had recurred sooner.
When the cancer is unresectable (has grown too large or spread too far to be surgically removed), chemotherapy and/or radiation therapy may be used to help relieve symptoms, such as pain, caused by the cancer or to shrink the tumor, so that surgery may become an option. If treatment is given only to relieve pain or bleeding, it is called palliative (relief-giving) therapy. It's very important to understand that palliative treatment is not expected to cure a cancer. Women with Stage IV vulvar cancer are encouraged to enter a clinical trial where they may receive new forms of therapy that may be beneficial but are as yet unproven.
Treatment of vulvar adenocarcinoma
If Paget's disease is present and there is no associated invasive carcinoma, treatment is wide local excision or simple vulvectomy. If an invasive adenocarcinoma of a Bartholin gland or of vulvar skin sweat glands is present, radical vulvectomy is recommended with inguinal (groin) lymph nodes removed on one or both sides.
Treatment of vulvar melanoma
Treatment options depend on how deeply the melanoma has invaded. If the depth is less than 0.75 mm, partial vulvectomy with 2 cm (about ¾ inch) margins is the usual treatment. Radical vulvectomy may be used when the lesion extensively involves the vulva.
WHAT WILL HAPPEN AFTER TREATMENT FOR VULVAR CANCER?
Each type of treatment for vulvar cancer could have side effects that may last from a few months to many years. A woman may be able to hasten her recovery by being aware of those side effects before treatment and by taking steps to minimize them and shorten their duration after treatment.
From the start, keep in mind that you must deal with your own individual physical and emotional factors. In the process of deciding what kind of treatment to have, for instance, you will find it helpful to discuss options with your family and friends, as well as with your primary care physician and nurse. At every step of pre-treatment, treatment, and recovery, you should talk with your cancer care team about side effects, ways to make them easier to tolerate, and the general outlook, or prognosis, of your case. They want to answer your questions, so ask them!
You may have special strengths, such as a healthy immune system, a history of excellent nutrition, a strong family support system, a deep faith. All of these can make a difference in how you respond to cancer. In fact, behavioral scientists have recently found that women who take advantage of a social support system, such as a cancer support group, survive with a better quality of life.
An important part of your treatment plan is a specific schedule of follow-up visits after surgery, radiation therapy, or chemotherapy to be sure what, if any, additional treatment is necessary.
Follow-up may involve procedures such as x-rays, CT scans, ultrasound studies, or MRI (magnetic resonance imaging) scans. There also may be biopsies to get tissue samples for microscopic evaluation, blood tests, and other examinations.
You can help in your own recovery from cancer by making healthy lifestyle choices.
If you use tobacco, stop now. Quitting will improve your overall health and the full return of the sense of smell may help you enjoy a healthy diet during recovery.
If you use alcohol, limit how much you drink. Have no more than one or two drinks per day.
Good nutrition can help you get better after treatment. Eat a nutritious diet. Most patients should eat more fruits, vegetables, whole grains, and high-fiber foods. However, if you develop diarrhea or cramping pain after radiation therapy, your health care team may recommend a low-fiber diet.
Begin a regular program of exercise when you and your health care team feel you are ready.
If you are in treatment for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. Give your body all the rest it needs so that you will feel better as time goes on.
A cancer diagnosis and its treatment is a major life challenge, with an impact on you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a meeting of a local support group. If you need individual assistance in other ways, contact your hospital's social service department or your American Cancer Society for help in contacting counselors or other services.
Finally, your cancer care team is always ready to help you understand your disease and treatment and to answer your questions about what you can do to improve your outlook for the future.
WHAT SHOULD YOU ASK YOUR PHYSICIAN ABOUT VULVAR CANCER?
It is important for you to have frank, open discussions with your cancer care team. They want to answer all of your questions, no matter how trivial you might think they are. Here are some questions to consider:
- What type of vulvar cancer do I have?
- Has my cancer spread beyond the vulva?
- What is the stage of my cancer and what does that mean in my case?
- What treatments are appropriate for me? What do you recommend? Why?
- What should I do to be ready for treatment?
- What are the risks or side effects that I should expect?
- Will I be able to have children after my treatment?
- What are the chances my cancer will recur (come back) with the treatment programs we have discussed?
- Should I follow a special diet?
- What is my expected prognosis, based on my cancer as you view it?
- What do I tell my children, husband, parents, and other family members?
In addition to these sample questions, be sure to write down your own. For instance, you might want specific information about anticipated recovery times so you can plan your work schedule. Or, you may want to ask about second opinions or about clinical trials for which you may qualify.