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Terms of Service Effective: January 4, 2010 Last updated: February 19, 2014 These Terms of Service (‘Terms’) govern your access to and use of the services, websites, and applications offered by Quora (the ‘Service’). Your access to and use of the Service is conditioned on your acceptance of and compliance with these Terms. By accessing or using the Service you agree to be bound by these Terms. Use of the Service You may use the Service only if you can form a binding contract with Quora, and only in compliance with these Terms and all applicable local, state, national, and international laws, rules and regulations. You must provide us accurate information, including your real name, when you create your account on Quora. We may, without prior notice, change the Service; stop providing the Service or features of the Service, to you or to users generally; or create usage limits for the Service. You are responsible for safeguarding the password that you use to access the Service and for any activities or actions under your password. We encourage you to use ‘strong’ passwords (that use a combination of upper and lower case letters, numbers and symbols) with your account. Quora will not be liable for any loss or damage arising from your failure to comply with this instruction. You represent that you are over the age of thirteen (13) years old. If you are over thirteen, but under the legal age of majority, your parent or legal guardian must consent to this Terms of Service and Privacy Policy, and affirm that they accept this Agreement on behalf of, and bear all legal and financial responsibility and liability for the actions of, any child between the age of 13 and majority, and expressly ratify and confirm any acts of any such child and all users of the account. User Content ‘Content’ means any information, text, graphics, or other materials uploaded, downloaded or appearing on the Service. You retain ownership of all Content you submit, post, display, or otherwise make available on the Service. Your License to Quora By submitting, posting or displaying Content on or through the Service, you grant us a worldwide, non-exclusive, royalty-free license (with the right to sublicense) to use, copy, reproduce, process, adapt, modify, publish, transmit, display and distribute such Content in any and all media or distribution methods (now known or later developed). You agree that this license includes the right for other users of the Service to modify your Content, and for Quora to make your Content available to others for the publication, distribution, syndication, or broadcast of such Content on other media and services, subject to our terms and conditions for such Content use. Such additional uses by Quora or others may be made with no compensation paid to you with respect to the Content that you submit, post, transmit or otherwise make available through the Service. We may modify or adapt your Content in order to transmit, display or distribute it over computer networks and in various media and/or make changes to your Content as are necessary to conform and adapt that Content to any requirements or limitations of any networks, devices, services or media. Additionally, by uploading content to the site, you warrant, represent and agree that you have the right to grant Quora the license described above. You also represent, warrant and agree that you have not and will not contribute any Content that (a) infringes, violates or otherwise interferes with any copyright or trademark of another party, (b) reveals any trade secret, unless the trade secret belongs to you or you have the owner’s permission to disclose it, (c) infringes any intellectual property right of another or the privacy or publicity rights of another, (d) is libelous, defamatory, abusive, threatening, harassing, hateful, offensive or otherwise violates any law or right of any third party, (e) creates an impression that you know is incorrect, misleading, or deceptive, including by impersonating others or otherwise misrepresenting your affiliation with a person or entity; (f) contains other people’s private or personally identifiable information without their express authorization and permission, and/or (g) contains or links to a virus, trojan horse, worm, time bomb or other computer programming routine or engine that is intended to damage, detrimentally interfere with, surreptitiously intercept or expropriate any system, data or information. Quora reserves the right in its discretion to remove any Content from the Site, suspend or terminate your account at any time, or pursue any other remedy or relief available under equity or law.Quora’s Licenses to You Subject to these Terms, Quora gives you a worldwide, royalty-free, non-assignable and non-exclusive license to re-post any of the Content on Quora anywhere on the rest of the web provided that the Content was added to the Service after April 22, 2010, and provided that the user who created the content has not explicitly marked the content as not for reproduction, and provided that you: (a) do not modify the Content; (b) attribute Quora by name in readable text and with a human and machine-followable link (an HTML <a> anchor tag) linking back to the page displaying the original source of the content on quora.com on every page that contains Quora content; (c) upon request, either by Quora or a user, remove the user’s name from Content which the user has subsequently made anonymous; (d) upon request, either by Quora or by a user who contributed to the Content, make a reasonable effort to update a particular piece of Content to the latest version on quora.com; and (e) upon request, either by Quora or by a user who contributed to the Content, make a reasonable attempt to delete Content that has been deleted or marked as not for reproduction on quora.com. You may only use the attribution required by this Section in the manner set out above. In exercising these rights, you may not implicitly or explicitly assert or imply any connection with, sponsorship or endorsement by Quora, or any Quora user of you or your use of the work, without the separate, express prior written permission of Quora or the Quora user. If you operate a search engine or robot, or you republish a significant fraction of all Quora Content (as we may determine in our reasonable discretion), you must additionally follow these rules: You must use a descriptive user agent header. You must follow robots.txt at all times. You must make it clear how to contact you, either in your user agent string, or on your website if you have one. Subject to these Terms, Quora gives you a personal, worldwide, royalty-free, revocable, non-assignable and non-exclusive license to use the Service as it is provided to you by Quora. Your Content will be viewable by other users of the Service and through third party services and websites. You should only provide Content that you are comfortable sharing with others under these Terms. All Content, whether publicly posted or privately transmitted, is the sole responsibility of the person who originated such Content. We may not monitor or control the Content posted via the Service. Any use of or reliance on any Content or materials posted via the Service or obtained by you through the Service is at your own risk. We do not endorse, support, represent or guarantee the completeness, truthfulness, accuracy, or reliability of any Content or communications posted via the Service or endorse any opinions expressed via the Service. You understand that by using the Service, you may be exposed to Content that might be offensive, harmful, inaccurate or otherwise inappropriate. Under no circumstances will Quora be liable in any way for any Content, including, but not limited to, any errors or omissions in any Content, or any loss or damage of any kind incurred as a result of the use of any Content made available via the Service or broadcast elsewhere. You are responsible for your use of the Service, for any Content you provide, and for any consequences thereof, including the use of your Content by other users and third party partners. You understand that your Content may be republished and if you do not have the right to submit Content for such use, it may subject you to liability. Quora will not be responsible or liable for any use of your Content by Quora in accordance with these Terms. We reserve the right at all times (but will not have an obligation) to remove or refuse to distribute any Content on the Service and to terminate users or reclaim usernames. We also reserve the right to access, read, preserve, and disclose any information as we reasonably believe is necessary to (i) satisfy any applicable law, regulation, legal process or governmental request, (ii) enforce the Terms, including investigation of potential violations hereof, (iii) detect, prevent, or otherwise address fraud, security or technical issues, (iv) respond to user support requests, or (v) protect the rights, property or safety of Quora, its users and the public. Quora Credits You agree that you have no right or title in or to any Quora credits you may receive or use in connection with the Service or any other attributes associated with your Account, regardless of how they were obtained. Instead, you receive only a limited right to use those credits in connection with certain features on Quora, such as the ‘Ask to Answer’ function. For more information regarding the rules applicable to Quora credits, see Quora’s’ rules and policies regarding Quora credits. Quora prohibits and does not recognize any purported transfers of Quora credits outside of the Service, or the purported sale, gift or trade of Quora credits in the ‘real world,’ unless Quora expressly authorizes such transfers in writing. Any such transfer or attempted transfer is prohibited and void, and Quora may cancel any credits transferred, assigned, or sold in violation of these terms or credits policies and rules. Quora may change the rules for transferring, receiving, or redeeming credits at any time for any reason. Quora also reserves the right to stop offering and/or supporting Quora credits at any time. Quora may expire, cancel, modify, or delete your Quora credits at any time for any reason, including for violations of these terms and conditions, or for no reason without notice to you. Quora may cancel any transaction if we believe that the transaction violates any of Quora’s terms or policies, or for no reason at all. Rules You must not do any of the following while accessing or using the Service: (i) use the Service for any unlawful purposes or for promotion of illegal activities; (ii) upload or post any Content (as defined above) in violation of the provisions contained in the ‘Your License to Quora’ section of these terms; (iii) use the Service for the purpose of spamming anyone; (iv) access or tamper with non-public areas of the Service, Quora’s computer systems, or the technical delivery systems of Quora’s providers; (v) probe, scan, or test the vulnerability of any system or network or breach or circumvent any security or authentication measures; (vi) access or search or attempt to access or search the Service by any means (automated or otherwise) other than through the currently available, published interfaces that are provided by Quora (and only pursuant to those terms and conditions), unless you have been specifically allowed to do so in a separate agreement with Quora (crawling the Service is permissible in accordance with these Terms, but scraping the Service without the prior consent of Quora except as permitted by these Terms is expressly prohibited); (vii) forge any TCP/IP packet header or any part of the header information in any email or posting, or in any way use the Service to send altered, deceptive or false source-identifying information; or (viii) interfere with or disrupt (or attempt to do so) the access of any user, host or network, including, without limitation, sending a virus, overloading, flooding, spamming, mail-bombing the Service, or by scripting the creation of Content in such a manner as to interfere with or create an undue burden on the Service. We may make available one or more APIs for interacting with the Service. Your use of any Quora API is subject to these terms and the Quora API Rules, which will be posted before we make these APIs available (as part of these Terms). Proprietary Rights All right, title, and interest in and to the Service (excluding Content provided by users) are and will remain the exclusive property of Quora and its licensors. The Service is protected by copyright, trademark, and other laws of both the United States and foreign countries. Except as expressly provided herein, nothing in the Terms gives you a right to use the Quora name or any of the Quora trademarks, logos, domain names, and other distinctive brand features. Any feedback, comments, or suggestions you may provide regarding the Service is entirely voluntary and we will be free to use such feedback, comments or suggestions as we see fit and without any obligation to you. The Service may include advertisements, which may be targeted to the Content or information on the Service, queries made through the Service, or other information. The types and extent of advertising by Quora on the Service are subject to change. In consideration for Quora granting you access to and use of the Service, you agree that Quora and its third party providers and partners may place such advertising on the Service or in connection with the display of Content or information from the Service whether submitted by you or others. Copyright Policy Quora respects the intellectual property rights of others and expects users of the Service to do the same. We will respond to notices of alleged copyright infringement that comply with applicable law and are properly provided to us. If you believe that your Content has been copied in a way that constitutes copyright infringement, please provide our copyright agent with the following information in accordance with the Digital Millennium Copyright Act: (i) a physical or electronic signature of the copyright owner or a person authorized to act on their behalf; (ii) identification of the copyrighted work claimed to have been infringed; (iii) identification of the material that is claimed to be infringing or to be the subject of infringing activity and that is to be removed or access to which is to be disabled, and information reasonably sufficient to permit us to locate the material; (iv) your contact information, including your address, telephone number, and an email address; (v) a statement by you that you have a good faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law; and (vi) a statement that the information in the notification is accurate, and, under penalty of perjury, that you are authorized to act on behalf of the copyright owner. Our designated copyright agent for notice of alleged copyright infringement or other legal notices regarding Content appearing on the Service is: Quora, Inc. Attn: Copyright Agent 650 Castro Street, Suite 450 Mountain View, CA 94041 Email:copyright@quora.com Please note that in addition to being forwarded to the person who provided the allegedly illegal content, we may send a copy of your notice (with your personal information removed) to Chilling Effects (www.chillingeffects.org) for publication and/or annotation. You can see an example of such a publication at http://www.chillingeffects.org/fairuse/notice.cgi?NoticeID=16887 A link to your published notice will be displayed on Quora in place of the removed content. We reserve the right to remove Content alleged to be infringing or otherwise illegal without prior notice and at our sole discretion. In appropriate circumstances, Quora will also terminate a user’s account if the user is determined to be a repeat infringer. Privacy Quora values your privacy. Please review our Privacy Policy to learn more about how we collect and use information about you via the Service. By using the Service you consent to the transfer of your information to the United States and/or other countries for storage, processing and use by Quora. Links The Service may contain links to third-party websites or resources. You acknowledge and agree that we are not responsible or liable for: (i) the availability or accuracy of such websites or resources; or (ii) the content, products, or services on or available from such websites or resources. Links to such websites or resources do not imply any endorsement by Quora of such websites or resources or the content, products, or services available from such websites or resources. You acknowledge sole responsibility for and assume all risk arising from your use of any such websites or resources. Third Party Beneficiaries — Medical and Legal Contributions All Quora users who provide answers to legal or medical questions are intended third-party beneficiaries (‘Legal & Medical Contributors’) of this section of the Terms of Use. The answers on this site are provided by Legal & Medical Contributors for informational purposes only. Quora and Legal & Medical Contributors TO THE FULLEST EXTENT PERMITTED BY LAW, DISCLAIM ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR PARTICULAR PURPOSE. In no event shall Quora or Legal & Medical Contributors be liable for any damages (including, without limitation, incidental and consequential damages, personal injury / wrongful death, lost profits, or damages resulting from lost data or business interruption) resulting from the use of or inability to use the Site or the Content, whether based on warranty, contract, tort, or any other legal theory, and whether or not Quora or its Legal & Medical Contributors is advised of the possibility of such damages. Neither Quora nor the Legal & Medical Contributors are liable for any personal injury, including death, caused by your use or misuse of the Site or Content. See Quora’s policy regarding questions and answers to medicine-related questions and Quora’s policy regarding questions and answers to law-related questions. Quora has provided certain disclaimer template language that Legal & Medical Contributors may edit and incorporate in their answers. Ethics rules rules differ by state, so we are not sure that this language will work for every attorney in every location — especially since rules can change over time. Legal & Medical Contributors should edit or add to disclaimer language as necessary to comply with their own state’s rules. As always, we do not monitor or control the Content posted via the Service; the answers and messages created by Legal & Medical Contributors are their sole creation and responsibility. We do not endorse or guarantee the completeness, truthfulness, accuracy, or reliability of any answers or messages posted by Legal & Medical Contributors, nor do we endorse any opinions they express. Answers to Medical Questions Content posted by Medical Contributors is not intended to be medical advice or instructions for medical diagnosis or treatment, and no physician-patient relationship is, or is intended to be, created by Content provided by Medical Contributors. If you think you may have a medical emergency, call your doctor or your local emergency number (911 in the United States) immediately. 1. Content is not a substitute for professional medical advice, examination, diagnosis or treatment. 2. You should not delay or forego seeking treatment for a medical condition or disregard professional medical advice based on Content. 3. You should always seek the advice of your physician or other qualified healthcare professional before starting or changing treatment. 4. Content should not be used to diagnose, treat, cure, or prevent disease without supervision of a doctor or qualified healthcare provider. 5. Content does not recommend or endorse any tests, physicians, products, procedures, opinions or other information. 6. Content is not regulated by the Food and Drug Administration or any state or national medical board. Information posted to Quora publicly or sent in an unsolicited message to a Medical Contributor is not confidential and does not establish a physician-patient relationship without the express consent of the Medical Contributor. Answers to Legal Questions Content posted by Legal Contributors in response to legal questions is not intended to be legal advice or form an attorney-client relationship. If you believe you have a legal claim, contact an attorney licensed in your state (or country) immediately to discuss your options. Most state bar associations have services to aid you in finding an attorney. For example, California residents should visit http://www.calbar.ca.gov/Public/Pamphlets/HiringaLawyer.aspx Content is provided for informational purposes only, with no assurance that the Content is true, correct, or accurate. No action should be taken, delayed, or deferred based on the Content. 1. Content is not a substitute for professional legal advice or a solicitation to offer legal advice regarding specific facts. Should you ignore this warning and send specific or confidential information in a private message or post it as a comment, there is no duty to keep that information confidential or to discontinue or forego any representation adverse to your interests. 2. You should not delay or forego seeking legal advice or disregard professional legal advice based on Content. Delay in seeking such legal advice could result in waiver of any claims you may have, depending on the applicable statute(s) of limitation. 3. Content is not regulated by any state or national bar association. 4. Information posted to Quora publicly or sent in an unsolicited message to a Legal Contributor is not confidential and does not establish attorney-client relationship without the express consent of the Legal Contributor. Reuse of Quora’s Policies, Disclaimers, & Terms of Use Language Regarding Legal & Medical Contributors In order to develop Web industry standards for online contributions by legal and medical professionals, Quora encourages other companies and organizations to adopt all or part of our policies, disclaimers, and terms of use language as part of their own products and terms of service. Quora therefore expressly permits other companies to copy and edit the provisions contained in this section of its terms of service for their own use. Additionally, Quora welcomes comments and suggestions on these terms as part of the ongoing debate regarding how professionals can comply with their professional responsibilities while being active, informative participants in online discussions. Disclaimers; Indemnity Your access to and use of the Service or any Content is at your own risk. You understand and agree that the Service is provided to you on an ‘AS IS’ and ‘AS AVAILABLE’ basis. Without limiting the foregoing, QUORA AND ITS PARTNERS DISCLAIM ANY WARRANTIES, EXPRESS OR IMPLIED, OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT. We make no warranty and disclaim all responsibility and liability for the completeness, accuracy, availability, timeliness, security or reliability of the Service or any content thereon. Quora will not be responsible or liable for any harm to your computer system, loss of data, or other harm that results from your access to or use of the Service, or any Content. You also agree that Quora has no responsibility or liability for the deletion of, or the failure to store or to transmit, any Content and other communications maintained by the Service. We make no warranty that the Service will meet your requirements or be available on an uninterrupted, secure, or error-free basis. No advice or information, whether oral or written, obtained from Quora or through the Service, will create any warranty not expressly made herein. TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, QUORA AND ITS AFFILIATES, OFFICERS, EMPLOYEES, AGENTS, PARTNERS AND LICENSORS WILL NOT BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION, LOSS OF PROFITS, DATA, USE, GOOD-WILL, OR OTHER INTANGIBLE LOSSES, RESULTING FROM (i) YOUR ACCESS TO OR USE OF OR INABILITY TO ACCESS OR USE THE SERVICE; (ii) ANY CONDUCT OR CONTENT OF ANY THIRD PARTY ON THE SERVICE, INCLUDING WITHOUT LIMITATION, ANY DEFAMATORY, OFFENSIVE OR ILLEGAL CONDUCT OF OTHER USERS OR THIRD PARTIES; (iii) ANY CONTENT OBTAINED FROM THE SERVICE; AND (iv) UNAUTHORIZED ACCESS, USE OR ALTERATION OF YOUR TRANSMISSIONS OR CONTENT, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE) OR ANY OTHER LEGAL THEORY, WHETHER OR NOT QUORA HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, AND EVEN IF A REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE. Some jurisdictions do not allow the exclusion of certain warranties or the exclusion or limitation of liability for consequential or incidental damages, so the limitations above may not apply to you. If anyone brings a claim against us related to your actions or Content on the Service, or actions or Content by or from someone using your account, you will indemnify and hold us harmless from and against all damages, losses, and expenses of any kind (including reasonable legal fees and costs) related to such claim. Open Source Licenses The Quora Service and Applications may contain or be provided together with open source software. Each item of open source software is subject to its own applicable license terms, which can be found at http://www.quora.com/about/open_source_tos and/or in the Quora application’s documentation or the applicable help, notices, about or source files. Copyrights to the open source software are held by the respective copyright holders indicated therein. General Terms These Terms and any action related thereto will be governed by the laws of the State of California without regard to or application of its conflict of law provisions or your state or country of residence. Unless submitted to arbitration as set forth in the following paragraph, all claims, legal proceedings or litigation arising in connection with the Service will be brought solely in Santa Clara County, California, and you consent to the jurisdiction of and venue in such courts and waive any objection as to inconvenient forum. For any claim (excluding claims for injunctive or other equitable relief) under these Terms where the total amount of the award sought is less than $10,000, the party requesting relief may elect to resolve the dispute through binding non-appearance-based arbitration. The party electing such arbitration shall initiate the arbitration through an established alternative dispute resolution (‘ADR’) provider mutually agreed upon by the parties. The ADR provider and the parties must comply with the following rules: a) the arbitration shall be conducted by telephone, online and/or be solely based on written submissions, as selected by the party initiating the arbitration; b) the arbitration shall not involve any personal appearance by the parties or witnesses unless otherwise mutually agreed by the parties; and c) any judgment on the award rendered by the arbitrator may be entered in any court of competent jurisdiction. These Terms are the entire and exclusive agreement between Quora and you regarding the Service (excluding any services for which you have a separate agreement with Quora that is explicitly in addition or in place of these Terms), and these Terms supersede and replace any prior agreements between Quora and you regarding the Service. The failure of Quora to enforce any right or provision of these Terms will not be deemed a waiver of such right or provision. In the event that any provision of these Terms is held to be invalid or unenforceable, the remaining provisions of these Terms will remain in full force and effect. We may revise these Terms from time to time. The most current version will always be on this page (or such other page as the Service may indicate). If the revision, in our sole discretion, is material we will notify you via posting to our website or e-mail to the email associated with your account. By continuing to access or use the Service after those revisions become effective, you agree to be bound by the revised Terms. If you are a U.S. government user (i.e., you have a .gov or .mil email address), see this addendum to the Quora Terms of Service (‘ToS’). The Service is operated and provided by Quora, Inc., 650 Castro Street, Suite 450, Mountain View, CA 94041. If you have questions about these Terms, please contact us at feedback@quora.com. Terms of Service Effective: January 4, 2010 Last updated: February 19, 2014 These Terms of Service (‘Terms’) govern your access to and use of the services, websites, and applications offered by Quora (the ‘Service’). Your access to and use of the Service is conditioned on your acceptance of and compliance with these Terms. By accessing or using the Service you agree to be bound by these Terms. Use of the Service You may use the Service only if you can form a binding contract with Quora, and only in compliance with these Terms and all applicable local, state, national, and international laws, rules and regulations. You must provide us accurate information, including your real name, when you create your account on Quora. We may, without prior notice, change the Service; stop providing the Service or features of the Service, to you or to users generally; or create usage limits for the Service. You are responsible for safeguarding the password that you use to access the Service and for any activities or actions under your password. We encourage you to use ‘strong’ passwords (that use a combination of upper and lower case letters, numbers and symbols) with your account. Quora will not be liable for any loss or damage arising from your failure to comply with this instruction. You represent that you are over the age of thirteen (13) years old. If you are over thirteen, but under the legal age of majority, your parent or legal guardian must consent to this Terms of Service and Privacy Policy, and affirm that they accept this Agreement on behalf of, and bear all legal and financial responsibility and liability for the actions of, any child between the age of 13 and majority, and expressly ratify and confirm any acts of any such child and all users of the account. User Content ‘Content’ means any information, text, graphics, or other materials uploaded, downloaded or appearing on the Service. You retain ownership of all Content you submit, post, display, or otherwise make available on the Service. Your License to Quora By submitting, posting or displaying Content on or through the Service, you grant us a worldwide, non-exclusive, royalty-free license (with the right to sublicense) to use, copy, reproduce, process, adapt, modify, publish, transmit, display and distribute such Content in any and all media or distribution methods (now known or later developed). You agree that this license includes the right for other users of the Service to modify your Content, and for Quora to make your Content available to others for the publication, distribution, syndication, or broadcast of such Content on other media and services, subject to our terms and conditions for such Content use. Such additional uses by Quora or others may be made with no compensation paid to you with respect to the Content that you submit, post, transmit or otherwise make available through the Service. We may modify or adapt your Content in order to transmit, display or distribute it over computer networks and in various media and/or make changes to your Content as are necessary to conform and adapt that Content to any requirements or limitations of any networks, devices, services or media. Additionally, by uploading content to the site, you warrant, represent and agree that you have the right to grant Quora the license described above. You also represent, warrant and agree that you have not and will not contribute any Content that (a) infringes, violates or otherwise interferes with any copyright or trademark of another party, (b) reveals any trade secret, unless the trade secret belongs to you or you have the owner’s permission to disclose it, (c) infringes any intellectual property right of another or the privacy or publicity rights of another, (d) is libelous, defamatory, abusive, threatening, harassing, hateful, offensive or otherwise violates any law or right of any third party, (e) creates an impression that you know is incorrect, misleading, or deceptive, including by impersonating others or otherwise misrepresenting your affiliation with a person or entity; (f) contains other people’s private or personally identifiable information without their express authorization and permission, and/or (g) contains or links to a virus, trojan horse, worm, time bomb or other computer programming routine or engine that is intended to damage, detrimentally interfere with, surreptitiously intercept or expropriate any system, data or information. Quora reserves the right in its discretion to remove any Content from the Site, suspend or terminate your account at any time, or pursue any other remedy or relief available under equity or law.Quora’s Licenses to You Subject to these Terms, Quora gives you a worldwide, royalty-free, non-assignable and non-exclusive license to re-post any of the Content on Quora anywhere on the rest of the web provided that the Content was added to the Service after April 22, 2010, and provided that the user who created the content has not explicitly marked the content as not for reproduction, and provided that you: (a) do not modify the Content; (b) attribute Quora by name in readable text and with a human and machine-followable link (an HTML <a> anchor tag) linking back to the page displaying the original source of the content on quora.com on every page that contains Quora content; (c) upon request, either by Quora or a user, remove the user’s name from Content which the user has subsequently made anonymous; (d) upon request, either by Quora or by a user who contributed to the Content, make a reasonable effort to update a particular piece of Content to the latest version on quora.com; and (e) upon request, either by Quora or by a user who contributed to the Content, make a reasonable attempt to delete Content that has been deleted or marked as not for reproduction on quora.com. You may only use the attribution required by this Section in the manner set out above. In exercising these rights, you may not implicitly or explicitly assert or imply any connection with, sponsorship or endorsement by Quora, or any Quora user of you or your use of the work, without the separate, express prior written permission of Quora or the Quora user. If you operate a search engine or robot, or you republish a significant fraction of all Quora Content (as we may determine in our reasonable discretion), you must additionally follow these rules: You must use a descriptive user agent header. You must follow robots.txt at all times. You must make it clear how to contact you, either in your user agent string, or on your website if you have one. Subject to these Terms, Quora gives you a personal, worldwide, royalty-free, revocable, non-assignable and non-exclusive license to use the Service as it is provided to you by Quora. Your Content will be viewable by other users of the Service and through third party services and websites. You should only provide Content that you are comfortable sharing with others under these Terms. All Content, whether publicly posted or privately transmitted, is the sole responsibility of the person who originated such Content. We may not monitor or control the Content posted via the Service. Any use of or reliance on any Content or materials posted via the Service or obtained by you through the Service is at your own risk. We do not endorse, support, represent or guarantee the completeness, truthfulness, accuracy, or reliability of any Content or communications posted via the Service or endorse any opinions expressed via the Service. You understand that by using the Service, you may be exposed to Content that might be offensive, harmful, inaccurate or otherwise inappropriate. Under no circumstances will Quora be liable in any way for any Content, including, but not limited to, any errors or omissions in any Content, or any loss or damage of any kind incurred as a result of the use of any Content made available via the Service or broadcast elsewhere. You are responsible for your use of the Service, for any Content you provide, and for any consequences thereof, including the use of your Content by other users and third party partners. You understand that your Content may be republished and if you do not have the right to submit Content for such use, it may subject you to liability. Quora will not be responsible or liable for any use of your Content by Quora in accordance with these Terms. We reserve the right at all times (but will not have an obligation) to remove or refuse to distribute any Content on the Service and to terminate users or reclaim usernames. 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Rehab Before Cancer Treatment Can Help Patients Bounce Back

Each lung cancer patient costs the NHS more than £9,000 a year, according to research published today.

The disease, which is mostly caused by smoking, costs far more to treat than any other cancer and has a devastating impact on the wider economy as well as a stark human cost, it is claimed.

Health economists at Oxford University estimate that the annual cost of lung cancer to the UK economy is around £2.4 billion, which includes the cost of treatment and premature death, the cost to business of sick leave and of unpaid care by friends and family.

Their research,

Rehab Before Cancer Treatment Can Help Patients Bounce Back

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This puts me in a unique position to help you, the patient, survive and thrive through any of the cancers listed on the drop down menu on this site.

Lung Cancer Stages: What are the Stages? | CTCA

Lung cancer stages

Small cell lung cancer staging

Small cell lung cancer stages are classified in one of two ways:

  • Limited stage: Cancer is in one lung, sometimes including nearby lymph nodes.
  • Extensive stage: Cancer has spread to the other lung, the fluid around the lung (the pleura) or to other organs in the body.

Non-small cell lung cancer staging

Non-small cell lung cancer staging uses the TNM system:

  • Tumor(T) describes the size of the original tumor.
  • Lymph node (N) indicates whether the cancer is present in the lymph nodes.
  • Metastasis (M) refers to whether cancer has spread to other parts of the body, usually the liver, bones or brain.

A number (0-4) or the letter X is assigned to each factor. A higher number indicates increasing severity. For instance, a T1 score indicates a smaller tumor than a T2 score. The letter X means the information could not be assessed.

Once the T, N and M scores have been assigned, an overall stage is assigned.

Stages of non-small cell lung cancer:

Stage IV lung cancer: Is cure possible? Thippeswamy R, Noronha V, Krishna V, Joshi A, Bal MM, Purandare N, Rangarajan V, Pramesh C S, Jiwnani S, Prabhash K – Indian J Med Paediatr Oncol

CASE REPORT

Year : 2013 | Volume : 34 | Issue : 2 | Page : 121-125

Stage IV lung cancer: Is cure possible?

Ravi Thippeswamy1, Vanita Noronha1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Nuclear Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Thoracic Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
1, Vamshi Krishna1, Amit Joshi1, Munita Meenu Bal2, Nilendu Purandare3, V Rangarajan3, CS Pramesh4, Sabita Jiwnani4, Kumar Prabhash1

Date of Web Publication

6-Aug-2013

Correspondence Address:
Kumar Prabhash
Room No 18, Main Building, Department of Medical Oncology, Tata Memorial Hospital Parel, Mumbai, Maharashtra – 400012
India

Source of Support: None, Conflict of Interest: None

2

DOI: 10.4103/0971-5851.116207

Reporting a case, 53 years old male with stage IV Nonsamall cell lung cancer in view of cytologically proven malignant pleural effusion. Usually the management of stage IV lung cancer is with palliative intent where the patient receives palliative chemotherapy along with palliative radiotherapy and surgery if required. Most of the data on curative management of oligometastatic non-small cell lung cancer includes patient with adrenal metastasis and some reports with brain metastasis. There is scarce literature on the surgical management of stage IV lung cancer with pleural effusion.

Keywords: Chemotherapy, cure, lung cancer, stage IV

How to cite this article:
Thippeswamy R, Noronha V, Krishna V, Joshi A, Bal MM, Purandare N, Rangarajan V, Pramesh C S, Jiwnani S, Prabhash K. Stage IV lung cancer: Is cure possible?. Indian J Med Paediatr Oncol 2013;34:121-5

How to cite this URL:
Thippeswamy R, Noronha V, Krishna V, Joshi A, Bal MM, Purandare N, Rangarajan V, Pramesh C S, Jiwnani S, Prabhash K. Stage IV lung cancer: Is cure possible?. Indian J Med Paediatr Oncol [serial online] 2013 [cited 2016 Feb 6];34:121-5. Available from: http://www.huonvalley.biz/?p=250

Lung cancer is one of the common differential diagnosis for, weight loss, lung mass, pleural effusion with lymphadenopathy in a male smoker in our country.The diagnosis requires high index of suspicion as it can be easily confused with tuberculosis and chronic bronchitis.The standard management of stage IV lung cancer with good performance status is palliative chemotherapy. Here we would like to discuss surgical options for oligometastic stage IV lung cancer with pleural effusion.

A 53-year-old male, chronic smoker, presented with history of left-sided dull aching chest pain for 1 month and significant weight loss of 5 kg in 1 month. There were no symptoms of breathing difficulty, hemoptysis, bony pains, or lumps noticed anywhere in body. Evaluation included a contrast-enhanced computed tomography (CT) of thorax which revealed a left upper lobe peripherally situated mass of size 2 2 cm involving chest wall, enlarged pretracheal, prevascular, and aortopulmonary window nodes, and mild left pleural effusion.

Differential diagnosis and diagnostic evaluation recommended

The common differential diagnoses for weight loss and lung mass with lymphadenopathy in a male smoker in our country are chronic obstructive lung disease, chronic bronchitis, tuberculosis, pneumonia, and lung cancer. Clinical history and thorough examination should be made with careful palpation of the neck for lymphadenopathy and chest auscultation. A chest radiograph is the basis of imaging and is complemented by a contrast-enhanced CT scan of the chest, which should include the liver and the adrenal glands. Tissue diagnosis is mandatory if the clinicoradiological suspicion of malignancy is high and a biopsy should be performed either by bronchoscopy or with CT guidance. If confirmed to be malignant, further staging workup would be required if the chest CT scan shows non-metastatic disease. A metastatic workup would include a positron emission tomography (PET)-CT scan and a magnetic resonance imaging (MRI) scan of the brain.

Our patient presented to us with a CT scan showing a left upper lobe mass with ipsilateral mediastinal lymphadenopathy and a small pleural effusion. His vitals were normal, physical examination was unremarkable, and ECOG performance status was 1. Fiber optic bronchoscopy showed no endobronchial growth. Diagnostic thoracentesis was performed. Pleural fluid cytology was positive for metastatic squamous cell carcinoma.

Role of cytology in lung cancer

Conventional cytologies such as sputum examination, bronchial lavage, bronchial brushings, fine-needle aspiration biopsy have played an important role in the diagnosis of primary and metastatic lung cancers. Immunohistochemical stains can be applied on cytological material. The immunohistochemical markers such as TTF-1, CK7, CK20, 4A4, 34 E12, and p63 help to classify further subtypes in Non-small cell lung cancer (NSCLC). In addition, epidermal growth factor receptor (EGFR) gene mutation studies can also be done on the blocks prepared from cytological material, which helps in choosing appropriate targeted therapy. Thus, cytology plays an important role not only to subclassify tumors but also to individualize treatment strategy with the advantage of easy availability and minimum invasiveness. [1]

Thus, the patient was diagnosed with squamous cell carcinoma of the lung, T3N2M1a, stage IV.

The standard management of stage IV lung cancer is palliative chemotherapy with platinum-based combination chemotherapy. However, there are some reports of patients with lung cancer with only a malignant pleural effusion and no other metastatic sites that have long-term cures with chemotherapy and surgery. [2],[3] In view of the excellent performance status of the patient and the PET-CT showing no other sites of metastases, it was decided that therapy with potentially curative intent could be attempted even though this would be a deviation from established guidelines. A staging workup was performed.

Staging evaluation of lung cancer

After establishing a tissue diagnosis, a complete staging workup is done to identify the presence of metastasis and for feasibility of surgical resection.

After detailed history and physical examination, laboratory investigations such as complete blood count, liver function tests (transaminases), serum electrolytes, serum calcium, and serum alkaline phosphatase are done. More than 80% of patients with an abnormality on evaluation have metastatic disease. Patients presenting with anorexia, weight loss, and fatigue have an especially poor prognosis which depicts advanced stage and aggressive tumor biology. [4]

Chest and abdomen CT and PET scans are routinely performed in patients with suspected metastatic lung cancer. Chest and upper abdomen CT scans help to identify hilar and mediastinal adenopathy and liver or adrenal metastases. CT chest has accuracy of 88% (80% sensitive and 100% specificity) in identifying mediastinal involvement. Integrated CT/PET has better sensitivity and specificity than CT or PET alone. [5]

Bronchoscopy with or without transbronchial needle aspiration, endobronchial ultrasound-guided transbronchial needle aspiration, video-assisted thoracoscopy, or mediastinoscopy has played an important role in evaluation of patients with suspected mediastinal involvement. Video-assisted thoracoscopy or mediastinoscopy has the advantage of directly visualizing the lesion and accurate sampling. Additional investigations are performed depending on clinical symptoms. Bone scanning and brain magnetic resonance imaging may be performed, depending on symptoms. [5]

PET/CT has good sensitivity and specificity in identifying distant metastases. [6] Thus, the PET/CT is very important in the decision-making process for a patient with NSCLC, especially so in a patient with oligometastases. Any suspicious lesion identified by PET/CT should be confirmed by histopathological evaluation. Various studies have reported that whole body PET detects occult metastases in 6-17% of NSCLC patients in whom conventional staging methods failed to identify the metastases. [7] PET/CT has positive predictive value of 54% in identifying additional lesions on top of the primary lung cancer. [8]

A PET-CT scan and an MRI scan of the brain showed absence of metastatic disease. The patient was counseled in detail regarding the standard recommended treatment of palliative chemotherapy alone, or an off-guideline option of chemotherapy followed by surgery if the response was good. The patient chose the latter option. The patient was given three cycles of chemotherapy with gemcitabine 1000 mg/m 2 day 1 and day 8 along with carboplatin AUC 5 (area under the curve, calculated by Calvert formula) on day 1 for every 21 days. He tolerated the chemotherapy well without major side effects. There was significant symptomatic benefit in the pain after the first cycle of chemotherapy.

Following three cycles of chemotherapy, PET-CT revealed a 1.9 1.6 1.2 cm left lingular lobe mass (SUV 3.5) with no abnormal activity in the mediastinal nodes and no distant metastases. We performed a left upper lobectomy with systematic mediastinal lymphadenectomy following which the patient had an uneventful post-operative recovery. Intra-operatively, a 2 2 cm left upper lobe lung mass was seen adherent to the pericardium with enlarged aortopulmonary AP window and left hilar nodes. There were no pleural nodules or effusion. The final histopathology showed no residual tumor with all regional nodes negative for metastasis (ypT0N0) [Figure 1].

Figure 1: Microscopy revealed large areas of necrosis, lymphoplasmacytic infiltrate, and hemosiderin deposits amidst areas of fibrosis. No residual tumor was identified (H and E, original magnification, ×100)

Click here to view

The patient is now alive and free of disease after a 24-month follow-up.

Assessment of pathological response to chemotherapy has played an important role in head and neck carcinomas, esophageal carcinoma, osteogenic sarcoma, and small cell lung carcinoma. Pathological complete response is defined as fibrosis or fibro inflammation without microscopic evidence of carcinoma and histologically negative nodes. Non-pCR is defined as any evidence of viable carcinoma, either at the primary site or at the resected regional LN. Those patients who achieve complete pathological response have long-term survival advantage. Junker et al. [9] found that in NSCLC patients, not only complete responders but also extensive responders with 10% residual tumor also had good long-term survival.

The common histological features of tumor regression are coagulative necrosis, fibrosis, foam cell/giant cell reaction, as well as mixed inflammatory infiltrate. The amounts of fibrosis correlate well with extent of tumor regression, which in turn is a surrogate marker of tumor response. Squamous carcinoma was associated with a higher probability of treatment response than adenocarcinoma. [9]

To conclude, pathological response can be of two types: Responder and non-responder groups. The common histological changes seen are fibrosis, necrosis, and foam cell/giant cell reaction; in some cases, increase in residual tumor nuclear grade is seen. The radiological assessments may not correlate well with the pathological response. [10]

NSCLC is the leading cause of cancer-related deaths worldwide. Brain, bone, liver, and adrenal gland are the most common extrapulmonary sites of distant metastases. [11] 20-50% of NSCLC will present with metastatic disease. Stage IV NSCLC cancer has an overall median survival time of 7-11 months. [12]

In the past, patients with stage IV disease were generally believed to be incurable. Patients with oligometastatic disease represent a distinct subset. After full evaluation, approximately 7% of patients with metastatic disease will have solitary metastasis. [13],[14] There is evidence that in such patients, survival benefit can be achieved with surgical resection. [15]

Accurate clinical staging is of utmost importance before embarking on curative surgery. FDG-PET/CT plays an important role in decision making and should be done if radical treatment is considered. The overall 5-year survival rate is about 28% for patients with satellite nodules and 21% for patients with ipsilateral pulmonary nodules. In patients with brain metastases, surgical resection achieves 5-year survival rates between 11% and 30%, and those with adrenalectomy for adrenal metastases have 5-year survival rates of 26%. [15]

Most of the data on curative management of oligometastatic NSCLC include patient with adrenal metastasis, brain metastasis, and few selected reports of patients with lung cancer with only a malignant pleural effusion and no other metastatic sites who have long-term cures with chemotherapy and surgery. [2],[3]

Brain metastases

Brain metastases have dismal prognosis without treatment, with median survival of 1-2 months. [16] Historically, whole brain radiation therapy (WBRT) was the standard of care in the management of brain metastases. 75% of patients had symptomatic neurological improvement with WBRT alone. However, this benefit is short-lived, with a median survival of only 3-6 months. Chronic neurological morbidities were seen in significant patients on follow-up. [17] With advances in surgical techniques, resection of solitary brain metastasis can be done with low surgical morbidity and mortality rates (0-3%). [4]

Stereotactic radiosurgery is an alternative approach to surgical resection in which high dose of focused radiation in a single fraction to a specific intra-cranial target is delivered, thus minimizing the unwanted radiation exposure to normal surrounding parenchyma. Recent data suggest that the combined treatment regime is beneficial for patients with a single brain metastasis. [18],[19]

Adrenal metastases

The adrenal gland metastatic involvement ranges from 18% to 42% in an autopsy series. [20],[21] Benign adenomas (2-9%) are common in general population, so the presence of an adrenal mass on imaging itself does not confirm metastasis. [21],[22] The prognosis and management depend on whether the mass is benign or malignant. PET-CT and an MRI do not definitively rule out malignancy, [22],[23] so histopathological confirmation is must before lung resection. The potential benefit of diagnostic laparoscopy over fine-needle biopsy alone is that it allows the exploration of the entire peritoneal cavity with a histological examination of suspected nodules. [23],[24] Moreover, laparoscopic adrenalectomy done for diagnostic purposes is itself a therapeutic modality for metastases. [24]

Other extrathoracic metastases

In NSCLC, most common sites for oligometastatic disease include the thorax, adrenals, and brain; metastases other than these sites are rare. There are two retrospective case series addressing this issue. [24],[13] Long-term survival was high, with a 5-year overall survival rate of 55.6% and a 10-year overall survival rate of 86% in reported series [13],[25] Based on the above two retrospective studies, three factors are considered important in selecting patients for resection: (a) the primary tumor should be completely resected; (b) metastases must be metachronous onset; and (c) there should be no other distant metastasis. [13]

Our patient was treated as stage IV NSCLC with curative intent as a deviation from established guidelines. In the absence of other distant metastases, he was given three cycles of neoadjuvant chemotherapy and underwent curative intent surgery. Complete pathological remission was achieved which has been rarely reported in literature.

The diagnosis of malignant pleural effusion with non-small cell carcinoma does not necessarily imply that patient has incurable disease. In selected subsets of patients, a cure may be possible after multimodality therapy. To properly select patients for an aggressive local treatment regime, accurate clinical staging is of prime importance. The use of FDG-PET should be considered for restaging if oligometastatic disease is suspected based on a patient’s CT scan. Our case report illustrates the potential role of curative intent surgery in stage IV lung cancer, with malignant pleural effusion but without distant metastases. The usefulness of PET-CT imaging in the staging and evaluation of response are also highlighted by the current study.

[Figure 1]

Rehab Before Cancer Treatment Can Help Patients Bounce Back

Cancer is costly. It can take a toll on your health, your emotions, your time, your relationships – and your wallet. There will be unexpected charges, and even the best health insurance won’t cover all your costs. Here are some tips on what costs you can expect and some ideas on how to plan for, ask about, and discuss treatment costs with your cancer care team. Don’t wait until you have financial problems to discuss cancer costs with your health care team.

You might feel as if you don’t have the energy to deal with cancer and talk about money, too. You might want to ask a friend or family member to keep track of costs for you. Ask this person to go with you to doctor visits and help with these discussions.

Learn as much as you can about cancer and your cancer treatment before it starts. This will help you know what to expect. It can also help you plan for and deal with the costs. Many people with cancer have medical expenses for things like:

  • Provider visits
  • Lab tests (blood tests, urine tests, and more, which are usually billed separately)
  • Clinic visits for treatments
  • Procedures (for diagnosis or treatment, which can include room charges, equipment, different doctors, and more)
  • Imaging tests (like x-rays, CT scans, and MRIs, which may mean separate bills for radiologist fees, equipment, and any medicines used for the test)
  • Radiation treatments (implants, external radiation, or both)
  • Drug costs (inpatient, outpatient, prescription, non-prescription, and procedure-related)
  • Hospital stays (which can include many types of costs such as drugs, tests, and procedures as well as nursing care, doctor visits, and consults with specialists)
  • Surgery (surgeon, anesthesiologist, pathologist, operating room fees, equipment, medicines, and more)
  • Home care (can include equipment, drugs, visits from specially trained nurses, and more)

Talk with the people on your cancer team. They’ll usually know who can help you find answers. Here are some questions you can ask about costs. Choose the ones that relate to you and your treatment.

The overall treatment plan

Here are some ideas for ways to bring up the subject of cost as your treatment is planned:

  • I’m worried about how much cancer treatment is going to cost me. Can we talk about it?
  • Will my health insurance pay for this treatment? How much will I have to pay myself? (Discuss this for each treatment option.)
  • I know this will be expensive. Where can I get an idea of the total cost of the treatment we’ve talked about?

Some related or follow-up questions you might want to ask:

  • If I can’t afford this treatment are there others that might cost less, but will work as well?
  • Is there any way I can get help to pay for this treatment?
  • Does my health insurance company need to pre-approve or pre-certify any part of the treatment before I start?
  • Where will I get treatment – in the hospital, your office, a clinic, or at home?

Prescription drugs

Oral chemotherapy

Today, more and more chemo drugs are taken by mouth. (This is often called oral chemo, and includes drugs known as targeted therapy.) In most cases, this means you get a prescription and take the drugs on your own, at home.

Chemo taken by mouth is as strong as the other forms and, when taken properly, works just as well. But oral chemo drugs cost a lot – sometimes many thousands of dollars each month. And most health insurance plans don’t pay for the oral drugs the same way they pay for the IV drugs (those put into a vein in the hospital, clinic, or office).

Oral chemo drugs are often treated like regular prescription drugs. You have to pay for them and, even if your insurance covers them, you might have a very high co-pay. For example, some insurance companies require a co-pay of 25% of the drug cost. This can be thousands of dollars. And this isn’t a bill that you can pay later – you have to pay when you pick up the drug at the pharmacy.

Make sure you know how much you’ll have to pay for each treatment. Many drug manufacturers have patient assistance plans to help people pay for their drugs. Ask your cancer care team about this.

Please see If You Have Problems Paying a Medical Bill or call us to learn more about this.

Other prescription drugs used with cancer treatment

Many kinds of drugs are used to treat cancer. These may be drugs to prevent nausea, treat pain, help with anxiety, or control diarrhea. Drug prices vary a lot. You (or a family member) may want to call different pharmacies to get an idea of where you can get the best price.

When your doctor prescribes medicines or outpatient care, here are some questions you may want to ask:

  • If I get outpatient treatment, how much of it will my health insurance cover?
  • How much will the chemo drug that I take by mouth cost me? What about the nausea medicines and other drugs that go along with it?
  • How much will I have to pay for this drug? Will my insurance cover it? (Ask this about each prescription you are given.)
  • Are there programs to help me get the drugs I need?
  • Are there less expensive drugs or a generic form that work as well?
  • Is there any other way I can get help paying for this drug?

Hospital, surgery, and clinic treatments

If you must have surgery, chemo, radiation, or will be in the hospital for part of your treatment, here are some questions you might want to ask:

  • Do we need to get my insurance company’s approval (sometimes called pre-certification) before the test, surgery, treatment, home care, etc.?
  • Is there a co-pay for each treatment? (The co-pay is the cost you will be charged each time you get outpatient treatments in an office or clinic. Your health insurance company sets the co-pay amount.)
  • If I must go into the hospital, how much will it cost? How much will my insurance cover?
  • Is there a way to know beforehand if the doctors who will see me in the hospital are in my health plan network?
  • Counting all the charges (hospital, anesthesia, surgeon, pathologist, and more), how much will this surgery cost me? How much will my insurance cover?
  • Should I plan for rehab, home care, or long-term care (such as nursing home or hospice care)?

Out-of-pocket costs are costs you have to pay because your health insurance doesn’t. They can add up quickly and may make it hard for you to pay for other things you need.

You’ll want to be sure that your health insurance company pays or reimburses the bulk of your medical expenses. This means you’ll need to

  • Know the terms of your policy
  • Be aware of preferred or network doctors, hospitals, or clinics
  • Keep careful records

If any of your treatments might be done by out-of-network doctors or providers, find out about those costs, too. Even when you know the terms of your policy, getting payments can mean re-submitting claims, appealing denials, and much more.

Usually, doctors’ offices and clinics have someone who handles health insurance concerns and problems. Ask your doctor if that person can help you with claims and codes on the bills that are sent to the insurance company.

You can find out more about health insurance and other costs at Understanding Health Insurance.

Our health insurance experts are also available to answer your questions 24 hours a day, 7 days a week. You can reach one of them by calling 1-800-227-2345.

We have a lot more information that you might find helpful. Explore www.cancer.org or call our National Cancer Information Center toll-free number, 1-800-227-2345. We’re here to help you any time, day or night.

National organizations and websites*

American Society of Clinical Oncology (ASCO)
Web site: www.cancer.net

    Has a special section for patients on the costs of cancer care at www.cancer.net/managingcostofcare. Also offers cancer and cancer-related information (including many in Spanish), on things like treatment, side effects, coping, and survivorship, as well as a database to help find an oncologist

Patient Access Network Foundation (PANF)
Toll-free number: 1-866-316-7263
Web site: www.panfoundation.org

    Helps under-insured patients with certain cancer diagnoses cover out-of-pocket costs related to cancer care.

Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Web site: www.patientadvocate.org

    Works with the patient and their insurer to resolve insurance problems; also provides direct financial support to insured patients who are financially and medically qualified for drug treatments and/or prescription co-pays, co-insurance, and deductibles related to certain cancer diagnoses.

American Society of Clinical Oncology. Managing the Cost of Cancer Care. Accessed at www.cancersupportcommunity.org/MainMenu/About-Cancer/Understanding-Cancer/Coping-with-the-Cost-of-Care/Where-do-I-begin.html on October 30, 2015.

Bestvina CM, Zullig LL, Yousuf Zafar S. The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature. Future Oncol. 2014;10(14):2189-2199.

Bullock AJ, Hofstatter EW, Yushak ML, Buss MK. Understanding patients’ attitudes toward communication about the cost of cancer care. J Oncol Pract. 2012;8(4):e50-58.

Cancer Support Community. Frankly Speaking About Cancer: Coping with the Cost of Care, 5 edition. Accessed at www.cancersupportcommunity.org/General-Documents-Category/Education/FSAC-Coping-with-the-Cost-of-Care.pdf on October 30, 2015.

Peppercorn J. The financial burden of cancer care: do patients in the US know what to expect? Expert Rev Pharmacoecon Outcomes Res. 2014;14(6):835-842.

Tangka FK, Trogdon JG, Richardson LC, et al. Cancer treatment cost in the United States: has the burden shifted over time? Cancer. 2010;116(14):3477-3484.

Ubel PA, Abernethy AP, Zafar SY. Full Disclosure – Out-of-Pocket Costs as Side Effects. N Engl J Med. 2013;369(16):1484-1486.

Improve Your Brain Function And Memory Retention

Many individuals desire to improve their brain function and also memory retention however are not positive how to start. It’s wise for a person to start out simply by transforming the way that they eat and working towards a healthier way of life to begin with. A healthy diet is going to increase the person’s health overall, together with their brain function and also memory retention. This doesn’t mean letting go of pretty much everything which is scrumptious and sticking to vegetables, it implies eating things in moderation and being mindful to take in adequate nutrients daily without overloading the body with excess calories.

When the person has a better basis with their diet regime anyone can include other things that could boost brain function and also memory retention. Taking in coffee has been proven to achieve these, however it is important to ensure it is a wholesome coffee. Replace cream as well as sugar with salt-free butter for a healthier early morning beginning. Furthermore, try acquiring ample sleep. It’s important to obtain eight hours of rest every night, however lots of people don’t get high quality slumber even though they generally do sleep for eight hours. Mobile phone applications can monitor the individual’s slumber to inform them of exactly how good their particular sleep cycle is and offer strategies to help them improve it.

Nootropics happen to be one more well-liked approach to increase brain function and also boost memory. They are health supplements that have an incredible quantity of advantages and also virtually no unwanted effects. Caffeine is just one instance of a nootropic many people take regularly. Finding the time to understand nootropics and precisely how they’re able to help can allow an individual to produce a custom-made health supplement that provides each of the benefits they may be trying to find. Dietary supplements could be combined together to strengthen both short-term and long-term memory, to be able to enhance concentration, in order to decrease nervousness and also exhaustion, and even more.

Take a peek over here at this page to be able to learn more about how to improve your brain function and memory. Easy steps might be simple to attain but still produce a significant difference. Make sure to visit site or go to my blog in order to learn much more about the many things you can do and how to incorporate all of them for an overall rise in brain function, memory, and even more.

The Right Chemical Mixer Can Make All the Difference

Not enough people understand the quantity of issues that they’ll encounter on a daily basis that might have never been present had it not been for the wmp chemical mixer. The volume of procedures handled simply by chemical mixers from white mountain process is simply incredible. From chemical salts to detergents, polyurethane to synthetic rubber, plastic fibers to ceramic pigments – living exactly as we know this might not have come to be possible devoid of such machines. The creation regarding these kinds of needed elements to normal modern day everyday life calls for an amazing amount of exactness as well as accuracy. Blenders have to be reputable, resilient, long-lived and also adaptive. Depending upon the specifications of one’s chemical mixing applications, you may want possibly minimal pace agitation, fast agitation or even a combination of the two, depending upon the particular viscosity of your required products. Numerous apps choose white mountain process chemical mixers with a shut down design for basic safety along with outward visual appearance.

When contemplating the purchase of a good unit for chemical compounds, it is crucial to take into account such issues as just how much it’ll cost to perform and keep, the benefit with which a new mixer might be utilized in your own process as well as whether or not stainless-steel or even high density polyethylene (HDPE) is the product best suited on your reasons. Other things to consider include things like total capacity, the ability to be autoclaved, and changeable Depending on the quantity of plans you provide, you may want to actually make your purchase having thought to versatility and changeability.

Distinct appliances contain varying heating abilities. They come both jacketed along with additionally, unjacketed, in addition to might be utilized not just to blend supplies, but more, in order to them down into reduced elements. They will range through large machines that may combine a variety of gallons for each minute to the people not very much more extraordinary than the usual your kitchen stand blender. Having the correct equipment pertaining to your own process will be essential. The correct mixing machine will probably conserve a person’s firm time, money and electrical power, and also will certainly aid you to definitely capitalize upon your current revenue by simply minimizing waste when creating a stable product. Irrespective of if you’re dissolving solids, producing emulsions, dispersions, suspending solids, blending together essential fluids or perhaps dispersing gases … the correct mixer makes all the difference.