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ByMarilynnMarchione and Kathleen Foody The Associated Press ATLANTA Surgery, drugs, radiation, comfort care. What's next for Jimmy Carter depends on how widely his cancer has spread and where, and how aggressively the 90-year-old former president wants to fight it. Carter said Wednesday that surgery Aug. 3 to re- move a mass in his liver revealed cancer that had spread to other parts of his body. He did not say whether the cancer started in his liver, or even if the or- igin is known. His father, brother and two sisters died of pancreatic cancer, and his mother had it, too. "There is clearly a fam- ily history of cancer, but we don't know if that plays a role in his current situa- tion," said Dr. Len Lichten- feld, deputy chief medical officer of the American Can- cer Society. What'snext? The first step is finding where the cancer started and spread. Are there a lot of little tumors in many places, or a couple large ones in places that are eas- ily accessible? "The process usually starts with imaging — CT scans or PET scans or ultra- sound — to try to get a sense of how extensive the cancer is, what organs are involved," said Dr. Efrat Dotan, a gas- trointestinal cancer spe- cialist at Fox Chase Cancer Center in Philadelphia. If a biopsy has been done, "pa- thologists often are able to say what the source is," just by studying the types of cells involved, she said. Why does it matter? It will tell doctors whether the cancer might be curable; cancer that has spread very widely usually is not. It also sug- gests whether the disease is treatable, with a reasonable chance of putting it into re- mission or meaningfully prolonging Carter's life. What if doctors can't find the origin? Sometimes the primary site remains a mystery. Even when it is known, some doc- tors do genetic analyses to see if there are mutations driving the tumor that can be targeted by some of the newer cancer medi- cines. A landmark federal study was just launched to test this approach — treat- ing patients on the basis of their tumor gene mutations rather than the site of ori- gin, such as breast or lung. What treatments might Carter have? If the cancer is in places where it can easily be re- moved, Carter may be a candidate for more surgery — he already tolerated one operation well. Focused radiation is sometimes used to treat tu- mors in areas that can't be easily operated on, such as the brain. Radiation also can help ease symptoms from tumors in places like the spinal cord or bone, and improve a patient's quality of life. Drugs can be considered, from traditional chemother- apy to newer medicines that target specific genes. Doctors also might advise Carter to join a clinical trial, which gives all cancer par- ticipants the current stan- dard of care plus a chance to try something new. What about his age? "Any treatment in a 90-year-old would be care- fully considered, both for its potential to help and the im- pact on quality of life and general health," and his doc- tors likely will explain his options in those terms, Lich- tenfeld said. "They're going to pay attention to his age but he's obviously someone who's been very active," not a frail older person, he said. Some chemotherapies can be especially tough, causing low blood cell counts that older people have a harder time han- dling. "Any treatment in older adults is more likely to cause more side effects," Dotan said. What if treatment can't prolong life? The key to informed de- cision-making is to under- stand the patient's goals, said Dr. Lodovico Bal- ducci, a specialist on treat- ing cancer in the elderly at the Moffitt Cancer Center in Tampa. Many people want to try everything possible to gain even a small amount of ex- tra time. On the other hand, "if someone says, 'I have lived a wonderful life; I want to die without pain,' then the best thing may be to do nothing" to fight the disease and in- stead focus on quality of life and comfort care, he said. What do Carter's acquaintances say? Carter gave his usual Sunday school lesson on Aug. 2, the day before his liver biopsy, and is still scheduled to teach eight more classes through Oc- tober, said Jeremy Shoulta, the pastor at Carter's Mara- natha Baptist Church in his hometown of Plains. "He has energy at 90 years old that I wish I had now at 31," Shoulta said. "He's going to move through the next few weeks with strength and give ev- ery effort to continue to live out the calling he has re- ceived in his life." Habitat for Humanity CEO Jonathan Reckford said Carter told him af- ter announcing his cancer that he and his wife Rosal- ynn still hope to help build 100 houses in Nepal this November. "I've never met someone with more deter- mination and resilience," Reckford said. FORMER PRESIDENT Location,extentofcancerwillgovernoptions .ELISEAMENDOLA‑THEASSOCIATEDPRESSFILE Jimmy Carter announced Wednesday he is fighting a cancer diagnosis.. By Eric Tucker The Associated Press WASHINGTON Two aides to former Secretary of State Hillary Clinton have agreed not to delete any work-re- lated documents follow- ing an order from a federal judge that they preserve the records, according to their lawyers. The pledges from Huma Abedin and Cheryl Mills are contained in court doc- uments submitted by the State Department as a part of a public records lawsuit brought by the conservative group Judicial Watch. That lawsuit sought re- cords related to Clinton's tenure as secretary of state, including documents about the work of Abedin, Clin- ton's deputy chief of staff at the time. U.S. District Judge Em- met Sullivan last week or- dered Abedin and Mills to preserve their emails and records, which their law- yers say they have agreed to do. The back-and-forth — in the same week that Clin- ton provided the Justice Department her private email server — suggests that trusted Clinton aides may also face scrutiny over emails and records in their possession. In addition, Clin- ton's lawyer, David Ken- dall, confirmed in a let- ter dated Wednesday that he last week voluntarily gave the Justice Depart- ment a thumb drive, along with two copies, containing roughly 30,000 emails from Clinton's tenure. Her pres- idential campaign made that acknowledgment on Tuesday as part of what it said was an effort to coop- erate with a federal inquiry into the security of Clinton's email setup. A lawyer for Platte River Networks, a Colorado-based technology services com- pany that began managing the Clinton server in 2013, said the firm voluntarily provided the server to the FBI on Wednesday. "This was a voluntary turnover, and it was done without subpoena," said Barbara Wells, a Denver at- torney, adding that she had been told that the company was not under investiga- tion. She said what the FBI wants to do with the server "is up to them. They have promised to maintain its se- curity." Clinton said in March she had exchanged about 60,000 emails during her four years in the Obama administration, about half of which were personal and deleted. She turned over the others to the State Depart- ment, which is reviewing and releasing them on a monthly basis. Last month, the inspec- tor general of the intelli- gence community raised concerns that classified in- formation had traversed the email server and referred the matter to the Justice Department. The referral did not al- lege any criminal wrong- doing, and Kendall, her attorney, has said federal authorities simply want as- surances that the emails continue to be properly stored. PUBLIC RECORDS LAWSUIT Cl in to n ai de s ag re e to p re se rv e em ai ls a e r ju dg e' s or de r FRIDAY, AUGUST 14, 2015 REDBLUFFDAILYNEWS.COM | NEWS | 3 B