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Pharyngeal Cancer

Our Approach
City of Hope offers a truly comprehensive approach to pharyngeal (throat) cancers. Our renowned head and neck surgeons specialize in the complex operations often necessary to eradicate these tumors while preserving vital structures and function.
 
We offer ultra-sophisticated radiotherapy techniques, such as IMRT and TomoTherapy. Finally, City of Hope employs the latest chemotherapy protocols and devises promising experimental therapies through its drug development research programs, then speeds them through patient clinical trials. These combined attributes allow us to provide powerful therapeutic options to patients fighting pharyngeal cancers.

Pharyngeal cancer patients at City of Hope receive treatment from a coordinated, multidisciplinary team of head and neck surgeons, plastic surgeons, oncologists, neurologists, radiation oncologists, nurses, nutritionists, speech pathologists and other supportive care specialists, ensuring the highest possible standard of care.

About Pharyngeal Cancer

Adapted from information provided by the National Cancer Institute

The term “throat cancer” can refer to either cancer of the pharynx or the larynx. Pharyngeal cancer occurs when cells in the pharynx become malignant and aggregate to form a tumor.

About the Pharynx

The pharynx is typically divided into three parts:
 
  • Nasopharynx – the upper part of the throat located behind the nasal cavity and above the soft palate.
  • Oropharynx – the middle part of the throat that lies behind the oral cavity. This is the part of the throat you can readily see when looking in the mirror. It allows food and fluids to pass from the mouth to the esophagus and air to flow into the lungs via the trachea.
  • Hypopharynx (sometimes called laryngopharynx) – the lower part of throat located behind the oropharnyx and adjacent to the larynx. It helps in swallowing and prevents aspiration.

All parts of the pharynx, along with the nasal cavity and paranasal sinuses, act as resonating chambers for sounds produced by the vocal cords in the larynx.

Categorized by Pharyngeal Region

Nasopharyngeal Cancer
Nasopharyngeal cancer is different from other pharyngeal cancers in several significant ways:
 
  • It is much more prevalent within Asian and Southeast Asian populations, with highest incidence in Southern China (Guangdong Province) and Taiwan
  • It is strongly correlated with infection by Epstein-Barr virus (EBV)
  • Some types are highly radiosensitive, and radiotherapy is the preferred treatment

Most nasopharyngeal cancers are squamous cell carcinomas. These can be subdivided into several forms, which vary in terms of cellular differentiation:
  • Keratinizing
  • Well-differentiated cells that produce keratin
    • More common in the United States; less common in Asia
    • Less associated with EBV infection
    • May be associated with traditional risk factors of head and neck squamous cell carcinoma such as tobacco use
    • Less radiosensitive and more radioresistant
    • Tends not to metastasize to distant sites, but is frequently locally invasive
  • Non-keratinizing (cells do not produce keratin)
    • Moderately-differentiated subtype
    • Tends to metastasize to regional lymph nodes
    • Variable radiosensitivity
    • Often linked to EBV infection
  • Undifferentiated subtype
    • Often occurs in conjunction with high numbers of lymphocytes, and may also be called lymphoepithelioma
    • More common in Asia
    • Most often associated with EBV infection
    • Tends to metastasize to regional lymph nodes
    • Very radiosensitive

Oropharyngeal Cancer

Like other pharyngeal cancers, most oropharyngeal cancers are squamous cell carcinomas. Sites within the oropharynx that may develop cancer are:
 
  • Base of the tongue
  • Tonsillar region (the most common site for primary cancers of the oropharynx)
  • Soft palate, which includes the uvula
  • Pharyngeal walls

Risk Factors for Oropharyngeal Cancer
 
  • Tobacco (both chewed and smoked) is strongly linked to developing oropharyngeal cancer.
  • Poor nutrition, specifically a diet low in fruits and vegetables that result in few dietary antioxidants
  • Heavy alcohol consumption
  • Eastern Asian decent
  • HPV (human papillomavirus) has been implicated as a major factor in the disease, with transmission occurring through oral sex.

Hypopharyngeal Cancers
Hypopharyngeal cancers are the least common type of pharyngeal cancer. Again, almost all cancers of this type are squamous cell carcinomas.

Risk Factors for Hypopharynceal Cancer
  • Excessive drinking
  • Smoking
  • Poor nutrition, specifically a diet low in fruits and vegetables that result in few dietary antioxidants
  • Male gender
  • HPV (human papillomavirus). While HPV is much more prevalent in oropharyngeal cancers, it has been found in some hypopharyngeal cancer patients. Its significance in the development of this cancer is unknown.

Pharyngeal Cancer Risk Factors

  • Age over 40
  • Male sex
  • Smoking
  • Chewing tobacco
  • Heavy alcohol use
  • Oral lichen planus (a chronic autoimmune disease manifesting as lacy white patches in the mouth or throat)
  • Human papillomavirus infection, especially in oropharyngeal cancers
  • Epstein-Barr virus infection, especially in nasopharyngeal cancers
  • Southern Chinese or South Asian ancestry, primarily in nasopharyngeal cancers
  • Diet low in fruits and vegetables/antioxidants (oropharyngeal/hypopharyngeal)
  • Plummer-Vinson syndrome (hypopharyngeal cancer)
  • Drinking matÈ, a stimulant drink common in South America (oropharyngeal cancer) Leukoplakia (white patches in the mouth or throat) (oropharyngeal cancer)
  • Erythroplakia (red patches in the mouth or throat) (oropharyngeal cancer)
  • Chewing betel quid, a stimulant commonly used in parts of Asia (oropharyngeal cancer)

Pharyngeal Cancer Staging

Source: National Cancer Institute

Staging is the process of finding out if and how far a cancer has spread.

Nasopharyngeal cancer

Stage 0 (Carcinoma in Situ) In stage 0, abnormal cells are found in the lining of the nasopharynx.  These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
In stage I, cancer has formed and is found in the nasopharynx only.

Stage II
Stage II nasopharyngeal cancer is divided into stage IIA and stage IIB as follows:

Stage IIA
Cancer has spread from the nasopharynx to the oropharynx (the middle part of the throat that includes the soft palate, the base of the tongue and the tonsils), and/or to the nasal cavity.

Stage IIB
Cancer is found in the nasopharynx and has spread to lymph nodes on one side of the neck, or has spread to the area surrounding the nasopharynx and may have spread to lymph nodes on one side of the neck. The involved lymph nodes are 6 centimeters or smaller.

Stage III

In stage III nasopharyngeal cancer, the cancer:

  • is found in the nasopharynx and has spread to lymph nodes on both sides of the neck and the lymph nodes are 6 centimeters or smaller; or
  • has spread into the soft tissues (oropharynx and/or nasal cavity) and to lymph nodes on both sides of the neck and the lymph nodes are 6 centimeters or smaller;or
  • has spread beyond the soft tissues into areas around the pharynx and to lymph nodes on both sides of the neck and the lymph nodes are 6 centimeters or smaller;or
  • has spread to nearby bones or sinuses and may have spread to lymph nodes on one or both sides of the neck and the involved lymph nodes are 6 centimeters or smaller.

Stage IV
Stage IV nasopharyngeal cancer is divided into stage IVA, stage IVB and stage IVC as follows:

Stage IVA
Cancer has spread beyond the nasopharynx and may have spread to the cranial nerves, the hypopharynx (bottom part of the throat), areas in and around the side of the skull or jawbone, and/or the bone around the eye. Cancer may also have spread to lymph nodes on one or both sides of the neck, and the involved lymph nodes are 6 centimeters or smaller.

Stage IVB
Cancer has spread to lymph nodes above the collarbone and/or the involved lymph nodes are larger than 6 centimeters.

Stage IVC
Cancer has spread beyond nearby lymph nodes to other parts of the body.

Oropharyngeal cancer
 
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the lining of the oropharynx. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
In stage I, cancer has formed and is 2 centimeters or smaller and has not spread outside the oropharynx.

Stage II
In stage II, the cancer is larger than 2 centimeters, but not larger than 4 centimeters, and has not spread outside the oropharynx.

Stage III
In stage III, the cancer is either:
  • larger than 4 centimeters and has not spread outside the oropharynx; or
  • any size and has spread to only one lymph node on the same side of the neck as the cancer. The lymph node with cancer is 3 centimeters or smaller.

Stage IVA
In stage IVA, the cancer either:
  • has spread to tissues near the oropharynx, including the voice box, roof of the mouth, lower jaw, muscle of the tongue or central muscles of the jaw, and may have spread to one or more nearby lymph nodes, none larger than 6 centimeters; or
  • is any size and has spread to one lymph node that is larger than 3 centimeters but not larger than 6 centimeters on the same side of the neck as the cancer, or to more than one lymph node, none larger than 6 centimeters, on one of both sides of the neck.

Stage IVB
In stage IVB, the cancer either:
 
  • surrounds the main artery in the neck or has spread to bones in the jaw or skull, to muscle in the side of the jaw or to the upper part of the throat behind the nose, and may have spread to nearby lymph nodes; or
  • has spread to a lymph node that is larger than 6 centimeters and may have spread to tissues around the oropharynx.

Stage IVC
In stage IVC, cancer has spread to other parts of the body; the tumor may be any size and may have spread to lymph nodes.
 
Hypopharyngeal cancer
 
Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the lining of the hypopharynx.  These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
 
Stage I
In stage I, cancer has formed in one area of the hypopharynx only and the tumor is 2 centimeters or smaller.
 
Stage II
In stage II, the tumor is either:

larger than 2 centimeters but not larger than 4 centimeters and has not spread to the larynx (voice box); or
found in more than one area of the hypopharynx or in nearby tissues.

Stage III
In stage III, one of the following is found:
 
 
  • The tumor is in only one area of the hypopharynx and is 2 centimeters or smaller; cancer has also spread to a single lymph node on the same side of the neck and the lymph node is 3 centimeters or smaller.
  • Cancer is in more than one area of the hypopharynx, is in nearby tissues, or is larger than 2 centimeters but not larger than 4 centimeters and is not in the larynx; cancer has also spread to a single lymph node on the same side of the neck and the lymph node is 3 centimeters or smaller.
  • The tumor is larger than 4 centimeters or has spread to the larynx; cancer may have spread to a single lymph node on the same side of the neck and the lymph node is 3 centimeters or smaller.

Stage IV
Stage IV is divided into stage IVA, IVB and IVC as follows:

In stage IVA, the tumor:
  • can be any size and has spread to nearby soft tissue, connective tissue, the thyroid or the esophagus; cancer may be found either in one lymph node on the same side of the neck (the lymph node is 3 centimeters or smaller) or in one or more lymph nodes anywhere in the neck (all of these lymph nodes are 6 centimeters or smaller);or
  • is in only one area of the hypopharynx, is 2 centimeters or smaller, and has also spread to one or more lymph nodes anywhere in the neck (all of these lymph nodes are 6 centimeters or smaller);

    or
     
  • is in more than one area of the hypopharynx, is in nearby tissues, or is larger than 2 centimeters but not larger than 4 centimeters and has not spread to the larynx; cancer has spread to one or more lymph nodes anywhere in the neck (all of these lymph nodes are 6 centimeters or smaller);or
  • is larger than 4 centimeters or has spread to the larynx; cancer has also spread to one or more lymph nodes anywhere in the neck (all of these lymph nodes are 6 centimeters or smaller).

In stage IVB, the tumor either:
 
  • has spread to nearby soft tissue, connective tissue, blood vessels, the thyroid or the esophagus, and may have spread to lymph nodes of any size; or
  • is any size and has spread to lymph nodes that are larger than 6 centimeters.
  • In stage IVC, cancer has spread beyond the hypopharynx to other parts of the body.
 

Pharyngeal Cancer Symptoms

Pharyngeal cancer may not have symptoms in the early stages. When present, symptoms may include the following:
 
Nasopharyngeal Cancer
 
  • A lump in the nose or neck
  • Sore throat
  • Trouble breathing or speaking
  • Nosebleeds
  • Trouble hearing
  • Pain or ringing in the ears
  • Headaches
 
Oropharyngeal Cancer
 
  • A sore throat that does not go away
  • A lump in the back of the mouth, throat or neck
  • Dull pain behind the breastbone
  • Cough
  • Trouble swallowing
  • Unexplained weight loss
  • Ear pain
  • Change in voice
  • Leukoplakia (white patches in the oropharynx)
  • Erythroplakia (reddish patches in the oropharynx)
 
Hypopharyngeal Cancer

  • A sore throat that does not go away
  • Ear pain
  • A lump in the neck
  • Painful or difficult swallowing
  • A change in voice
 

Pharyngeal Cancer Diagnosis

A variety of methods is used to diagnose pharyngeal cancers.
 
They include:
 
  • Physical exam and history
  • Head, neck and chest X-rays
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear MRI, or NMRI.
  • CT (computed tomography) scan: A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an X-ray machine. Contrast medium (a dye injected into a vein or swallowed to help the organs or tissues show up more clearly) is generally not used when imaging the sinonasal area. This procedure is also called computerized tomography or computerized axial tomography.
  • Positron emission tomography (PET) scan: A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose derivative fluorodeoxyglucose (FDG) is injected into a vein. The PET scanner rotates around the body and generates a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more FDG than normal cells do. PET scans may be used to find nasopharyngeal cancers that have spread to the bone. It has also been used to find distant metastases (primarily to the lungs) in hypopharyngeal cancers.
  • Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
  • Endoscopy: A procedure to look at organs and tissues inside the body to check for abnormal areas. An endoscope is inserted through the patients nose or mouth to look at areas in the throat that cannot be seen during a physical exam of the throat. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples for biopsy .
  • Biopsy: The removal of suspect tissue for analysis. A pathologist views the tissue under a microscope to look for cancer cells. This test is necessary to establish three things: 1) whether the tumor is benign or malignant, 2) what type of cell the tumor originated from and 3) what grade, or level of differentiation, the tumor cells display.
  • Human papillomavirus (HPV) test: Testing the blood or a biopsy sample for HPV may help reveal information about the cancer involved and provide treatment guidance.
     
For nasopharyngeal cancer:
 
  • Nasoscopy: A procedure to look inside the nose for abnormal areas. A nasoscope is inserted into the nose. A nasoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples for biopsy.
  • Neurological exam: A series of questions and tests to check the brain, spinal cord and nerve function. The exam checks a persons mental status, coordination and ability to walk normally, and how well the muscles, senses and reflexes work.
  • Epstein-Barr virus (EBV) test: Testing the blood or a biopsy sample for EBV may help reveal information about the specific type of nasopharyngeal cancer involved and provide treatment guidance.
 
Forhypopharyngeal cancer:
 
 
  • Barium esophagogram: An X-ray of the esophagus. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and X-rays are taken.
  • Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope (a thin, lighted tube) is inserted through the mouth or nose and down the throat into the esophagus. Tissue samples may be taken for biopsy.
  • Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and lungs. Tissue samples may be taken for biopsy.
 

Pharyngeal Cancer Treatment Options

Department of Surgery

Surgery is the preferred treatment for most pharyngeal cancers. If the cancer is considered localized, surgery may be performed if the tumor is considered surgically resectable and is likely to obtain clean surgical margins when the edges of the tissue removed do not contain tumor cells.

The surgeon will remove the cancer and possibly some surrounding tissue. In the event of suspected metastasis to local lymph nodes, a neck dissection will be performed and cancerous nodes removed. If a significant amount of tissue needs to be removed, reconstructive surgery may be required. In later-stage or aggressive cancers, near-total or total laryngopharyngectomy (removal of the larynx and pharynx) may be necessary. This has a significant impact on the patient, who may have to use an artificial larynx to speak.

A notable exception to the general rule of surgery being first-line treatment in pharyngeal cancers is nasopharyngeal cancer, which is primarily treated with radiotherapy. The keratinizing form of nasopharyngeal carcinoma is much less responsive to radiotherapy than the non-keratinizing forms, and would therefore benefit from surgery. Historically, surgical removal of tumors in the nasopharynx has proved difficult because of the complex anatomy of the region and the proximity of vital structures, which made access challenging. Now, modern techniques in skull base surgery may enable removal of certain tumors from the nasopharynx.

Radiotherapy

Because many types of pharyngeal cancers are advanced at diagnosis and/or prone to recurrence and metastasis, postoperative radiation therapy is often recommended to improve clinical outcomes. This is especially important in cases of higher-stage or larger tumors, or evidence of local invasion or metastasis.

Radiotherapy may be used by itself or in combination with chemotherapy in cases where the tumor may be too large to be surgically removed, where surgery would be unacceptably disfiguring, or if the tumor is inoperable for other reasons. Radiotherapy is also used as the primary treatment modality in most cases of nasopharyngeal cancer, as described above. Radiotherapy may also be useful as palliative treatment, i.e., to reduce symptoms such as pain and obstruction. Preoperative radiation may sometimes be employed in order to make the tumor more readily operable.

City of Hope's Radiation Oncology was the first in the western United States to offer the helical TomoTherapy Hi-Art System, one of the first radiation therapy systems of its kind to incorporate not only radiation therapy, but also tumor imaging capabilities comparable to a diagnostic computed tomography (CT) scan.

Two types of technology are integrated  spiral CT scanning and intensity modulated radiation therapy, or IMRT  thus producing hundreds of pencil beams of radiation (each varying in intensity) that rotate spirally around a tumor. The high-dose region of radiation can be shaped or sculpted to fit the exact shape of each patients tumor, resulting in more effective and potentially curative doses to the cancer. This also reduces damage to normal tissues and results in fewer complications.

Chemotherapy

Chemotherapy is sometimes used with radiation in cases of pharyngeal cancer where the disease is metastatic, unresectable and/or recurrent. It may also be employed postsurgically (along with radiation) in late-stage or aggressive cancers. Chemotherapy is rarely effective by itself in pharyngeal cancer, but is instead a valuable part of a multimodality treatment approach.

Chemotherapy regimens vary depending on the particular cell type in question. Sometimes, in order to use high-dose chemotherapy regimens (so as to destroy the maximum number of tumor cells), autologousperipheral blood stem cell transplantation is performed. This enables a rescue of the blood and bone marrow, which are hard hit by the intensive chemotherapy.

New Developments in Targeted Chemotherapy and Biologic Therapy

Studies suggest that three relatively new classes of drugs may show promise in treating pharyngeal cancers. The first is a drug class known as vascular endothelial growth factor (VEGF) inhibitors. These drugs are monoclonal antibodies that inhibit angiogenesis, the formation of new blood vessels necessary for tumors to continue growing and metastasizing. A VEGF inhibitor that has been used with some degree of success is bevacizumab (Avastin).

A second class of drugs is known as epidermal growth factor receptor (EGFR) inhibitors. EGFR is an oncogene, and its overexpression leads to uncontrolled cell growth, and thus cancer. Most pharyngeal cancers are known to overexpress EGFR. By inhibiting the EGFR gene, the drugs help to control tumor proliferation.

Immunotherapy in Advanced Nasopharyngeal Cancers

Because many nasopharyngeal cancers are associated with Epstein-Barr virus (EBV) infection, an immunotherapeutic treatment was devised to target this virus. Investigators isolated T cell s from the blood of EBV-positive nasopharyngeal cancer patients, and then modified the T cells to attack the EBV virus. Preliminary data suggest this approach can yield encouraging results.

Clinical Trials

City of Hope has several clinical trials involving experimental therapies for advanced solid tumors of the head and neck. Some of these may apply to pharyngeal cancers.  Click here for more information.

Follow-up

Because pharyngeal cancers often recur, patients should be followed closely for any signs of recurrence or metastasis. This is accomplished by regular physical exams that include thorough examination of the pharynx and neck as well as multiple imaging modalities, e.g., CT, magnetic resonance imaging and positron emission tomography scans.
 

Pharyngeal Cancer Resources

All of our patients also have access to the Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.

Additional Resources
 
SPOHNC (Support for People with Oral and Head and Neck Cancer)
P.O. Box 53
Locust Valley, NY 11560-0053
Phone: 800-377-0928
Fax: 516-671-8794
SPOHNC is a patient-directed self-help organization dedicated to meeting the needs of oral and head and neck cancer patients. Founded in 1991 by an oral cancer survivor, SPOHNC addresses the broad emotional, physical and humanistic needs of this population.
www.spohnc.org

Yul Brynner Head and Neck Cancer Foundation
135 Rutledge Ave.
MSC 550
Charleston, SC 29425-5500
Phone: 843-792-6624
Fax: 843-792-0546
Founded by the late actor Yul Brynner, a victim of smoking-induced head and neck cancer, this organization ‘s mission is to provide support to head and neck cancer patients throughout the year, to educate children and adults in the disease process, treatment and prevention of head and neck cancer, and to support ongoing research in head and neck oncology.
www.headandneck.org
www.yulbrynnerfoundation.org

WebWhispers
WebWhispers was started in 1996 for those who had questions about larynx cancer treatments, surgery, recovery and what life is like after laryngectomy surgery. It is now the largest support group for individual laryngectomee survivors of larynx and other throat cancers, offering advice from those who have been there and education at the time it is needed.
www.webwhispers.org

American Cancer Society
800-ACS-2345
866-228-4327 for TYY
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.
www.cancer.org

National Comprehensive Cancer Network (NCCN)
888-909- NCCN (6226)
The National Comprehensive Cancer Network (NCCN), an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
www.nccn.org

National Cancer Institute (NCI)
800-4-CANCER
The National Cancer Institute, established under the National Cancer Act of 1937, is the federal government's principal agency for cancer research and training.
www.cancer.gov

U.S. Dept. H&HS National Institutes of Health (NIH)
301-496-4000
301-402-9612 for TYY
The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health and Human Services.
www.nih.gov
 

Pharyngeal Cancer Team

Support This Program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact us below.

Kimberly Wah
Director
Phone: 213-241-7275
Email: kwah@coh.org

 
 
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City of Hope is committed to making the process of becoming a patient here as easy as possible. Call 800-826-HOPE (4673) or complete the Schedule a Callback form.
Our treatment facilities are located throughout our 100+ acre grounds in Duarte, California as well as in  Antelope Valley, South Pasadena, Santa Clarita and Palm Springs.
Led by multidisciplinary teams of volunteers and professionals, the Sheri & Les Biller Patient and Family Resource Center offers an integrated array of cancer support services.
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