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PROSTATE CANCER
( By JASCAP )

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Treatment for advanced prostate cancer

Overview of Treatments

The treatment options for advanced prostate cancer include hormonal therapy, surgery (to relieve symptoms), chemotherapy, radiotherapy (to relieve bone pain) and controlling symptoms.

Choosing treatment

Deciding on the best treatment is not always straightforward and a number of factors have to be taken into account. The most important of these are:

  • your general health
  • your age
  • where the cancer is and the symptoms it's causing
  • the likely side effects of treatment
  • your views about the possible side effects of treatment, and how much you are willing to risk side effects for the possible benefits in controlling the cancer
  • which treatments, if any, you have had before.

The possible treatments for your situation are likely to be discussed by a group of doctors working together. This is known as a multidisciplinary team and includes a doctor who specialises in treating conditions of the prostate (urologist), and doctors who are specialists in radiotherapy, hormonal therapy and chemotherapy treatments (clinical oncologists). The team may also include specialist nurses, social workers, and physiotherapists. It is common to see a surgeon, an oncologist and a specialist nurse to help you to make a decision about treatment.

Second opinion

Some people find it helpful to have another medical opinion to help them to decide about their treatment. Doctors can refer you to another specialist for a second opinion if you feel that this would be helpful

Treatment choices

When prostate cancer has spread beyond the prostate gland and is affecting other parts of the body, it can no longer be cured. However, treatment can usually be given to control the cancer for as long as possible, relieve any symptoms and improve quality of life.

Most men with advanced prostate cancer are recommended to have hormonal therapy. A range of hormonal therapies are available.

Surgery to remove the prostate gland is not suitable for men with advanced prostate cancer, but occasionally a trans-urethral resection of the prostate (TURP) can be useful to relieve problems with passing urine.

Chemotherapy may be used if hormone therapy is no longer able to control the cancer. Radiotherapy is sometimes used to treat bone pain.

Treatments to relieve symptoms may also be given, such as painkillers. Each of the treatments has different benefits and side effects.

Consent to treatment

Before you have any treatment, your doctor will explain its aims to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

You may feel that the hospital staff are too busy to answer your questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained to you.

You are also free to choose not to have treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatments for advanced prostate cancer

Your doctor will explain the benefits, possible disadvantages and side effects of the treatments to you. You can then decide what is best for your particular situation. The benefits and disadvantages of the treatments for advanced prostate cancer are outlined in the following pages. Before you have any treatment it is important that you are fully aware of them.

It is not possible for doctors to predict accurately who is going to be affected by the side effects of each treatment, so you need to be given full information about the risks beforehand and have plenty of opportunity to discuss them. Remember, there are often choices to be made about which treatment you should have, or even whether to have treatment. You can take as large or small a part in those choices as you wish.

Hormonal therapy

Hormonal therapy lowers the level of testosterone in the body, either by using tablets or injections, or by removing the testes.

Benefits: Can shrink the cancer and delay its growth, and relieve symptoms for many months or years.

Risks: It can cause a range of side effects that include breast swelling, hot flushes, impotence and lowered sex drive.

Chemotherapy

This is the use of anti-cancer (cytotoxic) drugs to kill cancer cells. Chemotherapy for prostate cancer is usually given as injections and drips (infusions) into a vein (intravenously).

Benefits: Can help to control the cancer and relieve symptoms if hormonal therapies are no longer working.

Risks: Chemotherapy can cause side effects, such as sickness, fatigue and hair loss.

Surgery

Surgery can be used to relieve symptoms of urinary obstruction (trans-urethral resection of the prostate - TURP).

Benefits: Can help relieve symptoms that occur when passing urine.

Risks of a TURP: There a very small risk of urinary incontinence. Some men have problems getting an erection after a TURP.

Radiotherapy

Radiotherapy uses high-energy rays to destroy cancer cells. It can be used to relieve symptoms of bone pain. This usually involves one or two treatment sessions given to the affected bone.

Benefits: Can help to relieve bone pain and strengthen a weakened bone. Usually has very few side effects - these are generally mild.

Risks: It can take 7-10 days for the radiotherapy to start reducing the pain and may take up to six weeks before the full effect is felt. Pain may become slightly worse before it gets better.

Hormonal therapy for advanced prostate cancer

About hormonal therapy

Hormonal therapy is the main treatment for men with advanced prostate cancer. It can shrink the cancer, delay its growth, and reduce symptoms. In order to grow, prostate cancer depends on the hormone testosterone produced by the testicles. Hormonal therapies reduce the amount or activity of testosterone in the body.

There are a range of hormonal therapies that can be used to treat advanced prostate cancer. If you have already had hormone treatment you may be advised to change to a different type. Hormonal therapies can be given as injections or tablets, or occasionally an operation (subcapsular orchidectomy) may be done to remove the part of the testicles that produces testosterone.

Hormonal treatment works well for most men with advanced prostate cancer, and the cancer can often be controlled for some time. Your doctor will monitor the cancer's response to the hormonal therapy by assessing any symptoms and examining you. Your PSA level will also be measured as this is usually a very good guide to the effectiveness of the treatment. If the cancer starts to grow again, your doctor may suggest you change to a different hormone therapy.

Although there are different medicines that can be used, at some point the cancer will stop responding to hormonal therapy. This is known as hormone-refractory prostate cancer . If hormonal therapy is no longer working, your doctor may suggest chemotherapy as an alternative treatment, or other palliative treatments to relieve symptoms.

Injections

Some drugs 'switch off' the production of hormones from the testicles by reducing the levels of a hormone produced by the pituitary gland. These drugs are called pituitary downregulators or gonadotrophin releasing hormone analogues (GnRH analogues) . They include goserelin (Zoladex®), leuprorelin (Prostap®) and triptorelin (Decapeptyl®).

They are usually given as a pellet injected under the skin of the abdomen (goserelin), or as a liquid injected under the skin or into a muscle (leuprorelin or triptorelin). Injections are given either monthly or every three months.

Tablets

Other hormonal therapy drugs work by attaching themselves to proteins (receptors) in the cancer cells. This blocks the testosterone from acting on the cancer cells. The drugs are called anti-androgens and are given as tablets. Commonly used antiandrogens are flutamide (Chimax®, Drogenil®), bicalutamide (Casodex®) and cyproterone acetate (Cyprostat®).

Anti-androgen tablets are also usually given for two weeks along with the first injection of a pituitary down-regulator. This prevents tumour flare, which is where symptoms can get worse after the first dose of treatment.

Anti-androgen withdrawal response

If hormonal therapy with an anti-androgen drug has been given for some months or years and the cancer begins to grow again despite the treatment, stopping the anti-androgen may make the cancer shrink for a while. This is known as an anti-androgen withdrawal response and occurs in up to one-quarter (25%) of men who stop anti-androgen therapy.

Side effects

Unfortunately most hormonal therapies can cause erection difficulties and loss of sexual desire for as long as the treatment is given. If the treatment is stopped, the problem may disappear. Some types of anti-androgens are less likely to cause impotence than others.

In some men who have hormonal therapies, the side effects that cause them the greatest problem are hot flushes and sweating. These stop if the treatment is stopped and the testosterone levels recover. In the meantime some medicines can help.

Hormonal treatment can also make you put on weight and feel tired, both physically and mentally. Some drugs (most commonly flutamide and bicalutamide) may also cause your breasts to swell and make them more tender. Your doctors may advise a short course of low- dose radiotherapy to your breasts before you start the drugs, to try to prevent swelling. If breast- swelling does occur then a tablet called tamoxifen may help ease this.

Some hormonal therapy, particularly GnRH therapy or removing the testicles, may increase your risk of developing diabetes or heart disease.

However, the benefits of hormonal treatment generally outweigh the possible risks. You can discuss the possible side effects with your doctor before you start treatment. Being warned about possible side effects can make them easier to cope with.

We have factsheets about individual hormonal therapies , with more information about how the drugs work and tips on coping with possible side effects.

Subcapsular orchidectomy (removal of testicles)

Subcapsular orchidectomy is a simple operation. A small cut is made in the scrotum (the sac that holds the testicles), and the part of the testicles that produces testosterone is removed. The scrotum will be smaller than before. The operation can be done under a local anaesthetic without the need to stay in hospital overnight. Sometimes both testicles are completely removed.

Some men find the idea of this operation very distressing and feel that it makes them less of a man. However, others do not find it a problem. Orchidectomy is as effective as pituitary down regulators and avoids the need for regular injections.

After the immediate effects - some pain, and often swelling and bruising of the scrotum - the side effects of hot flushes and sexual impotence are similar to those of hormonal therapy drugs.

Surgery for advanced prostate cancer

Surgery may be a treatment option for you. If you have advanced prostate cancer it's not beneficial to completely remove the prostate gland, but your doctors may suggest an operation called a TURP to relieve problems passing urine.

Some men may have surgery to remove their testicles (an orchidectomy). The aim of removing the testicles is to reduce the levels of testosterone in the body, so it is discussed in the section about hormonal therapies.

Make sure that you have discussed any operation fully with your doctor beforehand. It is important that you understand what it involves, including the chances of success, the likely side effects, and whether there are other treatment options that may be more appropriate to your particular circumstances.

Trans-urethral resection of the prostate (TURP)

A TURP is carried out if it is necessary to remove the part of the tumour that is blocking the urethra (the tube that drains urine from the bladder). A tube which contains a miniature microscope is passed through the urethra, into the prostate. A cutting instrument attached to the tube is then used to shave the inner area of the prostate to remove the blockage.

This can be done under a general anaesthetic or an epidural. With an epidural the lower body is numbed temporarily by injecting an anaesthetic into the spine so that you can't feel anything even though you are awake.

A TURP can't remove all of the cancer cells and is only used to relieve problems with passing urine.

After your TURP

After your operation you will probably be up and about the next morning. You will usually have a drip giving fluid into your vein. This will be taken out as soon as you are drinking normally. A tube (catheter) will drain fluid from your bladder into a collecting bag. It is usual for the urine to contain blood.

To stop blood clots from blocking the catheter, bladder irrigation may be used. This means that fluid is passed into the bladder and drained out through the catheter. The blood will gradually clear from your urine and the catheter can be taken out. At first you may find it difficult to pass urine without the catheter, but this should become easier. Some men find that they have some incontinence of urine following this procedure. It can also cause some long-term difficulty in passing urine.

Most men are able to go home after three or four days. Occasionally it is necessary to keep the catheter in for a while after you go home. If this is the case, the nurse will show you how to look after your catheter before you leave hospital, and arrangements can be made for a district nurse to visit you at home to help with any problems.

You may have pain and discomfort for a few days after your operation, for which you will be given painkillers. These are usually very effective, but if you continue to have pain it is important to let the doctor or nurse looking after you know as soon as possible so that a more effective painkiller can be found.

Following a TURP about 1 in 5 (20%) men may have retrograde ejaculation. This means that during ejaculation semen goes backward into the bladder, instead of forward through the urethra, so your urine may look cloudy after sex. This is harmless.

Care after an operation

If you think that you might have any difficulties coping at home after your surgery, let your nurse or social worker know when you are admitted to hospital so that help can be arranged. As well as being able to offer practical advice, many social workers are also trained counsellors who can offer valuable support to you and your family, both in hospital and at home. If you would like to talk to a social worker, ask your nurse or doctor to arrange it for you.

Before you leave hospital you will be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems you may have.

Chemotherapy for advanced prostate cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Although it is often used to treat cancer, it is less commonly used to treat cancer of the prostate.

When it is used

Chemotherapy is mainly used to treat advanced prostate cancer that is no longer being controlled by hormonal therapy (hormone-refractory prostate cancer). It is used in this situation to try to shrink and control the cancer and relieve symptoms, with the aim of prolonging a good quality of life. The chemotherapy drugs are usually given by injection into a vein (intravenously).

Two of the drugs used are docetaxel (Taxotere®) and mitoxantrone.

Sometimes, steroids (such as prednisolone) may be given alongside the chemotherapy.

Side effects

Chemotherapy drugs can cause side effects, but these can usually be well controlled with medicines. The doctors will look carefully at the possible advantages and disadvantages of chemotherapy treatment for your situation.

Each person's reaction to chemotherapy is different. Some people have very few side effects, while others experience more. The main side effects are described here, along with some of the ways they can be reduced.

Our section on chemotherapy discusses the treatment and its side effects in more detail. Information on individual drugs and their particular side effects is also available.

Lowered resistance to infection

Chemotherapy can reduce the production of white blood cells by the bone marrow, making you more prone to infection. Contact your doctor or the hospital straightaway if:

  • your temperature goes above 38C (100.5F).
  • you suddenly feel ill (even with a normal temperature).

You will have a blood test before having more chemotherapy, to make sure that your cells have recovered. Occasionally your treatment may have to be delayed if your blood count is still low.

Bruising or bleeding

Chemotherapy can reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, and bleeding gums.

Anaemia (low number of red blood cells)

You may become anaemic. This may make you feel tired and breathless.

Nausea and vomiting

Some chemotherapy drugs can make you feel sick or even be sick. This can be helped by taking antisickness drugs (anti-emetics), which your doctor can prescribe.

Sore mouth

Some chemotherapy drugs can make your mouth sore and may cause small ulcers. Regular mouthwashes are important and the nurses will show you how to do these properly.

Poor appetite

If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet.

Hair loss

Hair loss is a common side effect of some chemotherapy drugs. This can be very distressing for some people. However, there are many ways of covering up hair loss, including wigs, hats or scarves. You may be entitled to a free wig from the NHS. Your doctor or the nurse looking after you will be able to arrange for a wig specialist to visit you. If you do lose your hair, it should start to grow back within about 3-6 months of the end of treatment.

Tiredness

Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many find they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.

Although they may be hard to deal with at the time, these side effects will gradually disappear once your treatment is over. Your doctor will tell you what to expect from your treatment.

Radiotherapy for advanced prostate cancer

Radiotherapy may be given if the cancer has spread to other parts of the body, such as the bones. In this situation the treatment can't get rid of all the cancer cells and cure the cancer, but it can reduce symptoms such as pain, and make you more comfortable. This is known as palliative radiotherapy.

Palliative radiotherapy

If cancer of the prostate has spread to the bones, radiotherapy can be given to relieve pain. Treatment is given to the affected bone or area. It may be given as a single treatment, or may be divided into a series of smaller treatments. Many men notice that the pain eases within a couple of days, while others may have to wait three or four weeks. Painkilling drugs can still be taken if necessary.

The radiotherapy staff will explain your treatment and the possible side effects to you beforehand.

Occasionally, if there are cancer cells in more than one area of bone you may be given treatment known as hemibody irradiation. Treatment is given over a large area, either the top or the bottom half of the body. This type of radiotherapy normally gives good pain relief within a few days. However, the side effects of treatment are likely to be greater than with local radiotherapy to a given area. Your doctor will prescribe antisickness drugs for you and you may have a short stay in hospital. If necessary the other half of your body can be treated later, once the side-effects of treatment have worn off.

We have a booklet on secondary cancer in the bone which gives more detail about the possible treatments.

Strontium 89

This treatment for secondary cancer in the bone uses a radioactive material (isotope) called strontium 89, which is taken up by the affected areas of bone. It is particularly useful if several areas of bone are affected and are causing pain. The isotope is given as an injection into a vein in the arm; this can usually be done in the outpatients department. After the injection, a small amount of radioactivity is present in the urine, so men are advised to use flush toilets instead of urinals to reduce the risk of anyone else being exposed to the radiation.

The hospital staff will discuss any special precautions with you before you go home. The amount of radioactivity is very small and it is safe for you to be with other people, including children. Most men feel some effect from the treatment within a few weeks, although occasionally the pain may get slightly worse before it gets better.

Controlling symptoms of advanced prostate cancer

Advanced prostate cancer may cause unpleasant symptoms. The symptoms can be relieved by treating the cancer itself. Sometimes treatments work very quickly and you may notice an improvement within a few days. At other times treatments may take longer to work and it can be a couple of weeks before you begin to feel their full benefits.

Apart from treating the actual cancer there are many other ways to help relieve symptoms. This section gives ideas on what maybe helpful.

Pain

There are many different types of painkillers. They vary both in their strength and in the way they work. Some painkillers are better for certain types of pain and some suit certain men better than others. If you are taking painkillers, it is better to take them regularly, even if you are not in pain when the next dose is due. This is because painkillers not only relieve pain at the time, but work to prevent it from coming back. Painkillers can be taken as tablets, liquids or as suppositories (by insertion into the back passage). Some are also given as injections under the skin.

It is important to tell your doctor or nurse if the painkillers you are taking aren't easing your pain. Your doctor can either change the dose or change the painkillers to one that will be more effective for you.

Pain caused by advanced prostate cancer cells in a bone can be severe. Radiotherapy is very good at easing this type of pain, but can take a few weeks to work. Often, drugs containing morphine are needed while the treatment is being planned or while you are waiting for the radiotherapy to work.

Some men find that morphine makes them feel drowsy when they first start taking it, but this usually only lasts for a day or so. Taking morphine may also make some men feel sick at first, and they may need an anti-sickness tablet (anti-emetic) prescribed by the doctor for the first few doses. It may also cause constipation.

A number of other drugs can be helpful in relieving pain. If pain is due to prostate cancer cells in a bone, non-steroidal anti-inflammatory drugs (NSAIDs) can help. These drugs have few side effects other than sometimes irritating the lining of the stomach.

Drugs called bisphosphonates can also help to relieve bone pain. They may be given into a vein (intravenously) in the outpatient department every 3-4 weeks or be taken as tablets. Some of the tablets must be taken on an empty stomach an hour or so before food and may cause stomach upsets.

Bisphosphonates can help to strengthen bones and lower the risk of fractures. They can also reduce high levels of calcium in the blood (hypercalcaemia) as well as reducing pain. Bisphosphonates that may be used include clodronate (Bonefos® or Loron®), ibandronate and zoledronic acid (Zometa®).

Your doctor can also prescribe sleeping tablets, or a mild relaxant, which may be particularly helpful if you are having trouble sleeping because of the pain. Anxiety and lack of sleep can make pain worse. For this reason some men also find that practising relaxation techniques helps them feel more comfortable.

Heat and gentle massage can also help ease aches and pains. A good long soak in a warm bath, a well protected hot-water bottle, and some baby oil or lotion massaged into the skin can often make a difference.

Being in pain can make you feel very low and it is important to let your doctor know if the drugs prescribed aren't working. It is also important to keep in mind that there are many different ways to control pain. There are also special NHS pain clinics run by doctors and nurses expert in treating pain. You can ask your doctor to refer you to a pain clinic if your pain is not controlled by any of the above methods.

Weakness and numbness in the legs

If the bones in the spine are affected this can sometimes lead to weakness and tingling or numbness in the legs (due to pressure on the spinal nerves). If this is not treated the nerves may be permanently damaged. Treatment can often prevent damage, so if you develop any feelings of weakness, numbness or pins and needles in the legs, it is important to contact your cancer specialist immediately. Cancer in the spinal bones causing pressure on the spinal cord is known as malignant spinal cord compression.

Tiredness

You may find that you easily become very tired and that your body is no longer as strong and reliable as it once was, either because of the cancer, or because of the side effects of treatment.

You may feel as though you have no strength and everything is more of an effort.

It can be difficult to adjust if tiredness makes it difficult for you to drive or take part in sports, or if you have to walk more slowly than before. It will take time for you to get used to these changes and to accept having to rest, or not being able to do activities that you once took for granted.

If you have little energy, save it for the things you really want to do. Very often, re-organising your daily activities can be helpful - for example, by setting aside a time to rest every day. Practical aids such as wheelchairs can also be useful. You may feel that by using a walking stick, frame or wheelchair you are 'giving in' to your illness, but they can greatly improve your life, allowing you to move around more easily.

Sometimes the cancer or the treatment can cause anaemia, which can lead to tiredness. If this happens you may be given a blood transfusion, which can often give you more energy and reduce the tiredness.

Constipation

Constipation can be caused by strong painkillers, or if there is too much calcium in your blood (caused by prostate cancer cells affecting a bone). Constipation can also occur if you lose your appetite and you are not eating as much as before.

Having fibre in your diet, drinking plenty of fluids and walking will help, but you may also need to take a medicine to stimulate the bowel (a laxative). Your doctor will be able to prescribe a suitable one for you. Your nurses can also advise you on ways to prevent or relieve constipation.

Difficulty sleeping

Even though you may feel tired it is not uncommon for men with advanced prostate cancer to have difficulty sleeping. There can be many reasons for this, not least that you probably have a lot on your mind.

Sleeping tablets can be helpful, and the newer types are less likely to make you feel drowsy the following day. You can also try some natural remedies for sleeplessness - malted milk drinks before bed, a glass of brandy or whisky in the evening, warm baths with soothing bath oils, or a relaxing body massage to relieve muscle tension.

High levels of calcium in the blood (hypercalcaemia)

Prostate cancer cells affecting a bone may make extra calcium pass out of the damaged bone and into the blood. High levels of calcium in the blood can make you feel extremely tired and thirsty, and pass lots of urine. Hypercalcaemia can also make you feel sick and some people become irritable and confused. Depending on your calcium level, you may be able to have treatment as an outpatient or you may need to spend a few days in hospital.

Your doctor will give you drugs known as bisphosphonates. These drugs are given as a drip. Each treatment takes between 15 minutes and one hour, and can be repeated every few weeks. They are usually effective at getting the calcium levels back to normal. Your doctor may also ask you to start drinking plenty of water. Sometimes it may be necessary to use a 'drip' to give extra fluids into a vein in your arm (an intravenous infusion).

Strengthening a weakened bone

If prostate cancer cells have weakened a bone so much that there is a risk of it breaking, you may need an operation. This is done under a general anaesthetic. The surgeon will put a metal pin into the centre of the bone and may also fix a metal plate to the bone. This holds the bone firm so that it will not break. The pin and plate can stay in permanently to protect the bone. This is mainly used for the long bones in the legs but is sometimes used for secondaries in other bones, such as the spine. If your hip is affected, the hip joint may be replaced.

You will need to stay in hospital for a week, or longer, after the operation so that you can recover fully. However, most men are able to get up and start walking a couple of days after the surgery.

This sort of operation may be done before radiotherapy is given, if there is a chance the bone may break before the radiotherapy has treated the cancer cells.

If the doctors feel the bone is not likely to fracture, bisphosphonates may be used to help strengthen the bone and prevent it breaking.

Complementary therapies

Some men find that complementary therapies or practices can help them to feel stronger and more confident in dealing with advanced prostate cancer. They can usually be used alongside conventional treatments and medicines.

Complementary therapies can help to improve quality of life and wellbeing, and can sometimes help to reduce symptoms. Some complementary therapies, such as meditation or visualisation can be done by the person with cancer themselves and can reduce anxiety. Other therapies, such as gentle massage, can be carried out by relatives or carers and can help them to support the person.

Physical contact and touch can be among the most powerful forms of support for people who are faced with uncertainty, fear or pain, whether emotional or physical.

Many hospices and hospitals offer complementary therapies alongside conventional care. These may include: aromatherapy, colour and sound therapy, massage relaxation, visualisation or guided imagery techniques and acupuncture.


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