Important Questions to Ask
Let me help you by answering questions about your condition, your treatment, and your health. Since every case is unique, I am sure you will have your own list of questions for your care team, but here are some examples to get you started:
NOTE: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.
The stage of a cancer is a description (usually numbers I to IV with IV having more progression) of the extent the cancer has spread. The stage often takes into account the size of a tumor, how deeply it has penetrated, whether it has invaded adjacent organs, how many lymph nodes it has metastasized to (if any), and whether it has spread to distant organs. Staging of cancer is the most important predictor of survival. Cancer treatment is primarily determined by staging. However, patient’s cancer may be restaged after treatment but the staging established at diagnosis is rarely changed.
Cancer staging can be divided into a clinical stage and a pathologic stage. In the TNM (Tumor, Node, and Metastasis) system, clinical stage and pathologic stage are denoted by a small "c" or "p" before the stage (e.g., cT3N1M0 or pT2N0).
- Clinical stage is based on all of the available information obtained before a surgery to remove the tumor. Therefore, it may include information about the tumor obtained by physical examination, radiologic examination, and endoscopy.
- Pathologic stage adds additional information obtained from the examination of the tumor microscopically by a pathologist.
Clinical staging and pathologic staging often differ because they use different criteria. Pathologic staging is usually considered the "better" or "truer" stage because it allows direct examination of the tumor and its spread, contrasted with clinical staging which is limited by the fact that the information is obtained by making indirect observations at a tumor which is still in the body. However, clinical staging and pathologic staging should complement each other. Not every tumor is treated surgically; therefore pathologic staging is not always available. Also, sometimes surgery is preceded by other treatments such as chemotherapy and radiation therapy which shrink the tumor, so the pathologic stage may underestimate the true stage.
For most cancer, the stage is based on three main factors, T, N, and M:
- T: Stands for Tumor. It is based on the size of the original (primary) tumor and whether or not it has grown into nearby tissues.
- N: Stands for Node. It is whether or not the cancer has spread to nearby lymph nodes.
- M: Stands for Metastasis. It is whether or not the cancer has spread to distant area of the body.
Not all cancers are staged this way. This is because they grow and spread in a different way than some other tumors. For example, leukemias (cancers of blood) affect the blood and bone marrow throughout the body, and therefore are not staged based on these factors. Cancers in or around the brain are also not staged using the TNM staging system, since these cancers tend to spread to other parts of the brain and not to lymph nodes or other parts of the body.
Treatments for cancer are based on years of research both in the lab and in clinical trials. Treatment options are recommended based on the pathology of the cancer, stage of the disease, prior treatment, and patient’s overall physical condition. In some cases, only one specific cancer treatment may be generally accepted as appropriate. However, in many cases, several approaches and modalities can be used to target cancer, either alone or in combination together, and these include the use of chemotherapy, targeted therapy, radiation therapy, surgery, hormone therapy, biologic therapies, targeted therapy, stem cell transplants and clinical trials.
Treatments for cancer are always evolving. New discoveries are made and old methods are modified or discarded.
In order to make educated decisions regarding specific cancer treatments, it is necessary to go beyond testimonials and promises. You want to understand what the treatment is all about. A legitimate treatment method should meet certain standards; a questionable treatment does not meet any of them. These standards are:
- The method was studied scientifically and shown to be more effective than no cancer treatment at all.
- The benefits of the method clearly exceed any harm it might do. (You may need to ask specifically what problems people experienced on the treatment).
- Studies of the method have been properly conducted. An appropriate research design has been used, the studies have been subject to review by others knowledgeable in the field, the studies have been validated, and a human subjects committee has given the study its approval. Treatments for cancer that are said to work only in the hands of one practitioner are questionable by definition. New scientific therapies are always made available through meetings, talks and publications to the entire community of scientists and researchers.
Discuss with your oncologist the cancer treatment options that are available to you to treat your disease, how side effects of cancer treatments will be managed, what other resources are available to help you through your treatment. There are several resources available to person's undergoing treatment for cancer; oncology nurses, social workers, dieticians, support groups etc.
Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to destroy cancer cells. It works by stopping or slowing the growth of cancer cells, which grow and divide quickly. It can also harm healthy cells that divide quickly, such as those that line your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side effects. Often, side effects get better or go away after chemotherapy is over or discontinued.
Depending on your type of cancer and how advanced it is and as stated above, chemotherapy can cure cancer, control cancer or ease cancer symptoms (palliative care).
Chemotherapy is used in several ways to treat cancer:
Adjuvant chemotherapy: Chemotherapy given to destroy left-over (microscopic) cells that may be present after the known tumor is removed by surgery. Adjuvant chemotherapy is given to prevent a possible cancer reoccurrence.
Neoadjuvant chemotherapy: Chemotherapy given prior to the surgical procedure. Neoadjuvant chemotherapy may be given to attempt to shrink the cancer so that the surgical procedure may not need to be as extensive.
Induction chemotherapy: Chemotherapy given to induce a remission. This term is commonly used in the treatment of acute leukemias.
Consolidation chemotherapy: Chemotherapy given once a remission is achieved. The goal of this therapy is to sustain a remission. Consolidation chemotherapy may also be called intensification therapy. This term is commonly used in the treatment of acute leukemias.
Maintenance chemotherapy: Chemotherapy given in lower doses to assist in prolonging a remission. Maintenance chemotherapy is used only for certain types of cancer, most commonly acute lymphocytic leukemias and acute promyelocytic leukemias.
First line chemotherapy: Chemotherapy that has, through research studies and clinical trials, been determined to have the best probability of treating a given cancer. This may also be called standard therapy.
Second line chemotherapy: Chemotherapy that is given if a disease has not responded or reoccurred after first line chemotherapy. Second line chemotherapy has, through research studies and clinical trials, been determined to be effective in treating a given cancer that has not responded or reoccurred after standard chemotherapy. In some cases, this may also be referred to as salvage therapy.
Palliative chemotherapy: Palliative is a type of chemotherapy that is given specifically to address symptom management without expecting to significantly reduce the cancer.
During the past decade, targeted therapy has emerged as a new means of controlling and treating cancer. Several targeted therapies selectively act against molecular targets expressed in some tumors, and may interfere in tumor growth and progression.
Disruption of the normal regulation of cell-cycle progression and division lies at the heart of the events leading to cancer. Complex networks of regulatory factors, the tumor microenvironment and stress signals, such as those resulting from damaged DNA, dictate whether cancer cells proliferate or die. Recent progress in understanding the molecular biology and changes that underline cancer development, offer the prospect of specifically targeting malfunctioning molecules and pathways to achieve more effective and rational cancer therapy. Identifying tumor biomarkers when a diagnosis is made may help physicians choose an effective treatment while avoiding potentially ineffective ones. Moreover, as molecularly targeted therapy becomes more common, it may be increasingly important to assess therapeutic targets to help predict clinical response. In other words, targeted therapies and their associated biomarkers often 'co-evolve.'
There are three possible goals for chemotherapy treatment:
Cure: If possible, chemotherapy is used to cure the cancer, meaning that the cancer disappears and does not return. However, most doctors do not use the word “cure” except as a possibility or intention. When giving treatment that has a chance of curing a person’s cancer, the doctor may describe it as treatment with curative intent. However, there are no guarantees, and though cure may be the goal, it doesn’t always work out that way. It can also take many years to know if a person’s cancer is actually cured. Therefore, and as clinical oncologists, our ultimate goal in treating patients with cancer is to be able to cure their disease with a combination of other treatment modalities directed at the primary tumor (surgery or radiation), and potential metastases (chemotherapy).
Control: If cure is not possible, the goal may be to control the disease — to shrink any cancerous tumors and/or stop the cancer from growing and spreading. This can help someone with cancer feel better and possibly live longer. In many cases, the cancer does not completely go away but is controlled and managed as a chronic illness, much like heart disease or diabetes. In other cases, the cancer may even seem to have gone away for a while, but it’s expected to come back.
Palliation: When the cancer is at an advanced stage, chemotherapy drugs may be used to relieve symptoms caused by the cancer. When the only goal of a certain treatment is to improve the quality of life, it’s called palliative treatment or palliation.
1. The diagnosis of cancer must be established prior to receiving chemotherapy. Additionally, a proper clinical and pathological staging must be determined. All patients are required to sign consent form prior to the administration of any chemotherapeutic agents. A detailed description of the side effect profile of that specific agent will be discussed with the patient and all questions will be answered.
2. The patient must have a laboratory workup including complete blood count, kidney function and liver function. The values must fall within acceptable limits and will determine whether or not chemotherapy should be administered, dose may need to be adjusted, or the cycle may be delayed. In certain circumstances, an assessment of other organ function may be required like cardiac (heart) function, pulmonary (lung) function, etc.
3. The patient must have an acceptable performance status prior to the initiation of chemotherapy cycle. In medical oncology, performance status is defined as a quantitative measure of cancer patient’s general well-being and activities of daily life. This measure is used to determine whether patients can receive chemotherapy, whether dose adjustment is necessary, and as a measure for the required intensity of palliative care. It is also used in oncological randomized controlled trials as a measure of quality of life. There are several scoring systems that can be used to measure the performance status. The most generally used are the Karnofsky score and the ECOG score.
The Karnofsky score runs from 100 to 0, where 100 is "perfect" health and 0 is death. Although practitioners occasionally assign performance scores in between standard intervals of 10, there is no substantiated rationale for this and prognostication is not improved. This scoring system is named after Dr. David A. Karnofsky, an American specialist in cancer chemotherapy who described the scale with Dr. Joseph H. Burchenal in 1949. Karnofsky Score allows patients to be classified as to their functional impairment. Thus, the scale can be used to compare effectiveness of different therapies and to assess the prognosis in individual patients. Also, it is useful to track it over time, to see ups and downs in the disease process.
- 100% – normal, no complaints, no signs of disease
- 90% – capable of normal activity, few symptoms or signs of disease
- 80% – normal activity with some difficulty, some symptoms or signs
- 70% – caring for self, not capable of normal activity or work
- 60% – requiring some help, can take care of most personal requirements
- 50% – requires help often, requires frequent medical care
- 40% – disabled, requires special care and help
- 30% – severely disabled, hospital admission indicated but no risk of death
- 20% – very ill, urgently requiring admission, requires supportive measures or treatment
- 10% – moribund, rapidly progressive fatal disease processes
- 0% – death.
The ECOG score (published by Oken et al. in 1982), also called the WHO or Zubrod score (after C. Gordon Zubrod), runs from 0 to 5, with 0 denoting perfect health and 5 death. Its advantage over the Karnofsky scale lies in its simplicity. It is the method that is frequently used at our institution. In most of the cases, a performance status of 3 or above may disqualify the patient from receiving chemotherapy while a performance status of 0 and 1 does permit the use of chemotherapy. However, a performance status of 2 may qualify the patient to receive single agent chemotherapy or targeted therapy and this will be discussed with the patient in great detail.
- 0 – Asymptomatic (Fully active, able to carry on all pre-disease activities without restriction)
- 1 – Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)
- 2 – Symptomatic, <50% in bed during the day (Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours)
- 3 – Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
- 4 – Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
- 5 – Death
Chemotherapy is a "systemic" treatment, meaning that it works throughout the body to kill cancer cells. Traditional chemotherapeutic agents work by killing cells that divide rapidly. As they wipe out fast-growing cancer cells, though, they can also damage fast-growing healthy cells. It may be given before surgery or radiation to shrink a tumor or afterward to kill any cancer cells left behind or concurrently with radiation therapy like in lung cancer, anal cancer, rectal cancer and others.
Chemotherapy can cause damage to blood cells and may lead to side effects such as anemia, fatigue, and infections. Chemotherapy can also damage the cells that line the mucous membranes found throughout the body, including those inside the mouth, throat, and stomach. This leads to mouth sores, diarrhea, or other problems with the digestive system. It may also damage cells at hair roots, or hair follicles, leads to hair loss.
Each person with cancer reacts differently to chemotherapy and its various side effects. Fortunately, doctors now have many ways to reduce and even prevent these chemotherapy side effects and therefore cancer treatment is going more smoothly for many patients.
You should note that there are newer medications, known as targeted treatments. These medications were developed, in part, to cause less severe side effects than traditional chemotherapy. Many people taking these drugs develop a skin rash and other bothersome skin and nail conditions. Patients most likely to be affected are those taking a particular type of targeted treatment called an EGFR inhibitor. For a more comprehensive and detailed description of side effects that may be related to chemotherapy administration, please refer to the following Q&A “What are the side effects associated with chemotherapy use?”
The type, dose, schedule and duration of your chemotherapy are determined by your medical Oncologist. Administration of your chemotherapy is performed by chemotherapy certified nurses. All of our chemotherapy certified nurses have extensive knowledge and some good “down home” advice about how to get through treatment of your cancer as easily as possible.
Very few regimens require hospital admission nowadays. A few chemotherapy drugs come in an oral form and can be taken at home. Advances in the miniaturization of computerized chemotherapy infusion pumps allow many regimens that require prolonged, constant or continuous administration of these drugs to be given to you as an outpatient. By far the most common setting for chemotherapy administration, however, is in our specialized infusion center at Tallahassee Cancer Institute. This consists of a specially equipped room where chemotherapy certified nurses would administer bolus or short-infusion chemotherapy to you.
How often and how long you get chemotherapy depends on:
- The kind of cancer you have.
- The goals of the treatment.
- The drugs that are used.
- How your body responds to them.
You may get treatment every day, every week, or every month. Chemotherapy is often given in cycles that include treatment periods alternated with rest periods. Rest periods give your body a chance to build healthy new cells and regain its strength. Certainly, the issue of how long and how often you will be receiving chemotherapy will be discussed with you by our medical team in great detail.
Sticking with your treatment schedule is very important for the drugs to work right. Schedules may need to be changed for holidays and other reasons. If you miss a treatment session or skip a dose of the drug, contact your doctor.
Sometimes, your doctor may need to delay a treatment based on the results of certain blood tests. This is extremely important for your safety and certain guidelines are strictly followed in this regard. Your doctor will let you know what to do during this time and when to start your treatment again.
Chemotherapy can be given in several different ways:
- Intravenously. Chemotherapy is most often given intravenously (IV), through a vein. Usually a thin needle is inserted into a vein on the hand or lower arm at the beginning of each treatment session and is removed at the end of the session. However, patients who need to have many IV treatments may have chemotherapy delivered by IV through catheters (soft, thin, flexible tubes), ports (small round plastic or metal discs placed under the skin), or pumps. These can stay in place as long as needed and eliminate the need for needle sticks at each treatment.
- By mouth (orally). The drug is given in pill, capsule, or liquid form. You swallow the drug, just as you do with many other medicines.
- Intramuscularly, or IM (Into a muscle).
- Subcutaneously, or SQ or SC (Under the skin).
- Intralesionally or IL (Directly into a cancerous area in the skin).
- Intraperitoneally (Directly into the peritoneal cavity).
- Intrathecally (Into the cerebrospinal fluid either directly or through a special reservoir).
- Topically. The drug is applied on the surface of the skin.
Most people receiving chemotherapy find that they tire easily, but many feel well enough to continue to lead active lives. Each person and treatment is different, so it is not always possible to predict exactly how you will react. Your general state of health, the type and extent of cancer you have, and the kind of drugs you are receiving can all affect how well you feel.
You may want to have someone available to drive you to and from treatment if, for example, you are taking medicine for nausea or vomiting that could make you tired. You may also feel especially tired from the chemotherapy as early as one day after a treatment and for several days. It may help to schedule your treatment when you can take off the day of, and the day after, your treatment. If you have young children, you may want to schedule the treatment when you have someone to help at home the day of and at least the day after your treatment. Ask your doctor when your greatest fatigue or other side effects are likely to occur.
Most people can continue working while receiving chemotherapy. However, you may need to change your work schedule for a while if your chemotherapy makes you feel very tired or have other side effects. Talk with your employer about your needs and wishes. You may be able to agree on a part-time schedule, find an area for a short nap during the day, or perhaps you can do some of your work at home.
Under Federal and state laws, some employers may be required to let you work a flexible schedule to meet your treatment needs. To find out about your on-the-job protections, check with a social worker, or your congressional or state representative.
Some medicines may interfere or react with the effects of your chemotherapy. Give your doctor a list of all the medicines you take before you start treatment. Make sure to include:
- The name of each drug
- The dosage
- The reason you take it
- How often you take it
Remember to tell your doctor about all over-the-counter remedies, including vitamins, laxatives, medicines for allergies, indigestion, and colds, aspirin, ibuprofen, or other pain relievers, and any mineral or herbal supplements. Your doctor can tell you if you should stop taking any of these remedies before you start chemotherapy. After your treatments begin, be sure to check with your doctor before taking any new medicines or stopping the ones you are already taking.
A number of medical tests are done before chemotherapy is started. The oncologist will determine how much the cancer has spread from the results of x-rays and other imaging studies and from samples of the tumor taken during surgery or biopsy.
Blood tests give the doctor important information about the function of the blood cells and levels of chemicals in the blood. A complete blood count (CBC) is commonly done before and regularly during treatment. The CBC shows the numbers of white blood cells, red blood cells, and platelets in the blood. Since chemotherapy affects the bone marrow, where blood cells are made, levels of these cells often drop during chemotherapy. The white blood cells and platelets are most likely to be affected by chemotherapy. A drop in the white blood cell count means the immune system cannot function properly. Low levels of platelets can cause a patient to bleed easily from a cut or other wound. A low red blood cell count can lead to anemia (deficiency of red blood cells) and fatigue.
When a chemotherapy treatment takes a long time, the patient may prepare for it by wearing comfortable clothes. Bringing a book to read or a tape to listen may help pass the time and ease the stress of receiving chemotherapy. Some patients bring a friend or family member to provide company and support during treatment. It is also recommended to bring food, snacks and drinks while receiving chemotherapy to combat hunger and thirst.
You may want to have someone available to drive you to and from treatment if, for example, you are taking medicine for nausea or vomiting that could make you tired. You may also feel especially tired from the chemotherapy as early as one day after a treatment and for several days.
Sometimes, patients taking chemotherapy drugs known to cause nausea are given medications called anti-emetics before chemotherapy is administered. Anti-emetic drugs help to lessen feelings of nausea. The most common medications that may be used to fight nausea are Reglan, Decadron, low-dose Ativan, Zofran, Emend and Sancuso. These drugs will be given to you as a prescription and dispensed to you by your pharmacy that you may require to bring with you the day of your chemotherapy session. Sancuso patch is the only FDA approved drug used transdermally in cancer patients for the treatment of nausea and vomiting. The Sancuso patch attaches to the skin with a thin layer of adhesive. Once applied, the patch releases Granisetron, an established inhibitor of nausea and vomiting, slowly and continuously. The drug enters the patient’s bloodstream transdermally. A single application of the Sancuso patch provides up to 5 consecutive days of relief from nausea and vomiting in patients receiving a moderately or highly nausea-inducing chemotherapy regimen. Other antinausea medication like Aloxi, Kytril, Zofran, and Fosaprepitant, may be administered to you intravenously just prior to starting chemotherapy at our clinic.
Other ways to prepare for chemotherapy and help lessen nausea are:
- regularly eating nutritious foods and drinking lots of fluids
- eating and drinking normally until about two hours before chemotherapy
- eating high carbohydrate, low-fat foods and avoiding spicy foods
Although it is an effective treatment for many types of cancer, chemotherapy - like other cancer treatments - can cause side effects. The types and intensity of side effects vary from person to person and with the type and location of cancer, the treatment dose, and the person's health. You may have a lot of side effects, some, or none at all. This depends on the type and amount of chemotherapy you get and how your body reacts. Before starting chemotherapy, your doctor will discuss the side effects that you are most likely to get with the drugs you will be receiving. Also, you will be asked to sign a consent form. You should be given all the facts about treatment, including the drugs you will be given and their side effects, before you sign the consent form.
Chemotherapy targets cells that are actively growing - a characteristic of cancerous cells - but does not distinguish between actively growing normal cells (such as cells in the blood, mouth, intestines, and hair) and cancerous cells. Side effects occur when the chemotherapy damages normal, healthy cells that maintain the body's function and appearance. However, doctors and scientists are continually working to identify new drugs, methods of administering (giving) chemotherapy, and combinations of existing treatments that have fewer side effects. As a result, many types of chemotherapy are easier to tolerate than medications used even a few years ago. In addition, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects. Your health care team will work with you to ease or prevent many of these side effects.
Common Side Effects of Chemotherapy:
Different drugs cause different side effects. Although specific side effects may be predictable for certain classes of drugs, each person's experience with chemotherapy is unique. Talk with your doctor about specific side effects that you may experience or are experiencing. With most types of chemotherapy, the presence and intensity of side effects are not measures of how well the treatment is working. However, some side effects of targeted therapy do, in fact, indicate the medication’s effectiveness.
Common side effects of chemotherapy include:
Fatigue: Fatigue (a persistent sense of tiredness or exhaustion) is the most common symptom reported by patients receiving chemotherapy.
Sores in the Mouth and Throat: Chemotherapy can damage the cells that line the mouth and throat. The sores (also called mucositis) usually develop five to 14 days after receiving chemotherapy and can become infected. However, they usually heal completely when treatment is finished. Patients receiving chemotherapy who have poor diets and/or poor dental hygiene increase their risk of mouth and throat sores.
Diarrhea: Certain chemotherapy causes loose or watery bowel movements. Preventing diarrhea or treating it early can help a person avoid becoming dehydrated (the condition when the body does not get the amount of fluids it needs) or developing other problems.
Nausea and Vomiting: Chemotherapy can cause nausea (an urge to vomit, or throw up) and vomiting - a risk that depends on the type and dose of chemotherapy. With appropriate medications, nausea and vomiting can be prevented in nearly all patients.
Constipation: Chemotherapy - as well as some drugs to treat nausea and vomiting, pain, depression, diarrhea, and blood pressure - may cause constipation, the infrequent or difficult passage of stool. Patients may also increase their risk of constipation by not drinking enough fluids, eating balanced meals, or getting enough exercise.
Blood Disorders: Chemotherapy affects production of new blood cells in the bone marrow, the spongy, inner mass of the bone.
A test called a complete blood count (CBC) will indicate the levels of red blood cells (RBCs), white blood cells (WBCs), in the blood. An abnormally low level of RBCs results in anemia. This condition decreases the body’s ability to carry oxygen throughout the body, resulting in fatigue, dizziness, or shortness of breath. A lower than normal number of WBCs (called leukopenia) increases the body’s risk of infection.
A second type of test, called a platelet count, measures the number of platelets (blood cells that stop bleeding by plugging damaged blood vessels and helping the blood to clot) in your blood. People with thrombocytopenia (a shortage of platelets) bleed and bruise more easily.
These conditions can be treated with medications that stimulate the bone marrow to make more blood-forming cells that develop into RBCs, WBCs, and platelets.
Nervous System Effects: Some drugs cause nerve damage, resulting in one or more of the following nerve- or muscle-related symptoms:
- Weakness or numbness in the hands and/or feet
- Weak, sore, tired, or achy muscles
- Loss of balance
- Shaking or trembling
- Stiff neck
- Visual problems
- Walking problems
- Difficulty hearing
These symptoms usually decrease when the chemotherapy dose is lowered or treatment is stopped; however, in some cases, the damage is permanent.
Changes in Thinking and Memory: Some patients experience difficulty thinking clearly and concentrating after chemotherapy. Cancer survivors often refer to this side effect as "chemo brain," while doctors may refer to it as cognitive changes or cognitive dysfunction.
Sexual and Reproductive Issues: Chemotherapy can affect sexual function and fertility (a woman’s ability to conceive a child or maintain a pregnancy and a man’s ability to father a child). Talk with your doctor about the possible sexual and reproductive side effects before treatment begins.
In addition, chemotherapy is capable of harming the fetus during pregnancy, particularly if given during the first trimester of pregnancy when the fetus' organs are still developing. Women should take precautions to avoid pregnancy during treatment and inform their doctor if they become pregnant.
Appetite Loss: People receiving chemotherapy may eat less than usual, not feel hungry at all, or feel full after eating only a small amount. Ongoing appetite loss can lead to weight loss, malnutrition, and loss of muscle mass and strength, which can hinder the body’s ability to recover from chemotherapy.
Pain: Chemotherapy can cause pain for some people, including mouth sores, headaches, muscle pain, stomach pain, and pain from nerve damage, such as burning, numbness, or shooting pains (most often in the fingers and toes). Pain often eventually diminishes, but some people may have persistent symptoms for months or years from permanent damage to the nerves. Doctors can treat pain by treating the source of the pain; changing the perception of pain, usually with pain-relieving medications; or interfering with pain signals sent to the brain through spinal treatments or nerve blocks.
Hair Loss: Patients receiving chemotherapy may lose hair throughout the body, gradually or in clumps. This side effect most often starts after the first several weeks or rounds of chemotherapy and tends to increase one to two months into treatment. Hair regrowth after chemotherapy usually occurs one to three months after maintenance therapy starts or after intensive chemotherapy ends.
Skin and Nail Changes: Some of the most common side effects affecting patients who undergo chemotherapy occur as problems with the skin. These problems are typically short-lived, and by observing a few precautions and paying special attention to skin care, they are usually manageable. Skin problems brought on by chemotherapy tend to affect the skin overall, while problems caused by radiation therapy are almost always limited to the area being treated. A patient who is undergoing chemotherapy and radiation therapy simultaneously is at increased risk for skin problems from both, and their severity may be increased as well.
The skin care problems associated with chemotherapy are not dissimilar to those caused by radiation therapy, i.e., redness, itching, scaling, and peeling. However, these problems tend to be more systemic than localized, and generally result in overall skin dryness.
Additionally, certain chemotherapeutic agents may affect the nails. You may see a line in the nail related to the cycle of chemotherapy. This line is not permanent and grows out with the nail, usually in about six months. There may even be multiple lines and indentations reflecting the different cycles of chemotherapy.
Your nails may become pigmented or discolored. They may become more brittle, so they won't grow as long as they used to and may break more easily.
The area around the nail bed may become dry, and your cuticles may fray. Don't rip or peel off the loose cuticle. Cut it carefully with a CLEAN pair of nail scissors.
The nail may actually lift off the nail bed. While this, too, is reversible, you need to be very careful, for two reasons. First, the nail is more vulnerable and may fall off. Second, because the nail is not tightly bound to the nail bed, it can become a site for bacteria to enter. Be sure to practice excellent hygiene to avoid infection.
Nail care is first-line prevention for lymphedema, a condition that develops when lymph fluid accumulates in the soft tissues of the arm, causing it to swell. If you've had an underarm lymph node dissection with mastectomy or lumpectomy, you should be particular careful of damage to the nail, such as hangnails or cuts or burns on the hands or fingers, which could lead to infection.
Long-term Side Effects: Many side effects of chemotherapy disappear at the end of treatment. However, some side effects may persist, recur, or develop later. For instance, certain types of chemotherapy are associated with permanent organ damage to the heart, lung, liver, kidneys, or reproductive system. In addition, some people find that cognitive functions (such as thinking, concentrating, and memory) remain a challenge for months or years after treatment. Meanwhile, nervous system changes can develop months or years after treatment and cancer survivors have a higher risk of developing second cancers later in life. Follow-up care is essential for all cancer survivors and may include regular physical examinations and/or medical tests to monitor recovery in the months and years after cancer treatment. You may need to visit the American Society of Clinical Oncology website (ASCO) at www.asco.org which offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.
Normal cells usually recover when chemotherapy is over, so most side effects gradually go away after treatment ends, and the healthy cells have a chance to grow normally. The time it takes to get over side effects depends on many things, including your overall health and the kind of chemotherapy you have been taking.
Most people have no serious long-term problems from chemotherapy. However, on some occasions, chemotherapy can cause permanent changes or damage to the heart, lungs, nerves, kidneys, reproductive or other organs. Certain types of chemotherapy may have delayed effects, such as a second cancer, that show up many years later.
Ask your doctor about the chances of any serious, long-term effects that can result from the treatment you are receiving (but remember to balance your concerns with the immediate threat of your cancer).
Great progress has been made in preventing and treating some of the common as well as rare serious side effects of chemotherapy. Many new drugs and treatment methods destroy cancer more effectively while doing less harm to the body's healthy cells.
The side effects of chemotherapy can be unpleasant, but they must be measured against the treatment's ability to destroy cancer. Medicines can help prevent some side effects such as nausea. Sometimes people receiving chemotherapy become discouraged about the length of time their treatment is taking or the side effects they are having. If that happens to you, talk to your doctor or nurse. We may be able to suggest ways to make side effects easier to deal with or reduce them.
It is not good to skip a chemotherapy treatment. However, sometimes your doctor or nurse may change your chemotherapy schedule. Usually, a missed dose is because the patient is not tolerating the chemotherapy well. Oncologists monitor this "toxicity" to the patient and may reduce or hold doses of chemotherapy based on your current state of health and your recovery from previous doses. For example, if your white cell counts are unacceptably low, your oncologist may change your dose levels or have you wait a week before the next chemo to give your body time to recover. Work with your oncologist to monitor your condition to determine when it's safe to restart chemotherapy for the maximum healing effect. Your oncologist or nurse will explain what to do and when to start treatment again. If, however, you missed your dose because of non-health related circumstances, such as weather that prohibited you from driving, you need to contact your oncologist's office as soon as possible to promptly restart treatment.
General tips for helping to control side effects after chemotherapy include:
- Following any instructions given by the doctor or nurse.
- Taking all prescribed medications.
- Eating small amounts of bland foods.
- Drinking lots of fluids.
- Getting plenty of rest.
Medication that can be prescribed by your physician to manage some of the side effects of chemotherapy would include antinausea drugs, use of appetite stimulants, occasional use of antibiotics to prevent infection, and use of bone marrow boosters (growth factors) to stimulate the bone marrow to make red cells or white cells.
1. Appetite Loss:
The first step in treating appetite loss is to treat the underlying cause. Treatment for conditions such as mouth sores, dry mouth, pain, or depression should help improve appetite. Additional treatment for appetite loss and associated weight loss may include appetite-stimulating medications, medications that help food move through the intestine, nutritional supplement drinks, and tube feeding (often a nasogastric tube that passes through the nose into the stomach).
Although you may not feel like eating, it is important to remember that good nutrition and maintaining a healthy weight are important parts of overall cancer care and recovery. Eating well can also help a person better cope physically and emotionally with the effects of cancer and cancer treatment. The following guidelines may be helpful in maintaining proper nutrition when your appetite is poor.
- Eat five to six small meals a day and snack whenever you are hungry.
- Determine what times of day you are hungry, make sure to eat at those times, and do not limit how much you eat.
- Eat nutritious snacks that are high in calories and protein (for example, dried fruits, nuts, yogurt, cheeses, eggs, milkshakes, ice cream, cereal, pudding, and granola bars).
- Keep favorite foods on hand for snacking.
- Add calories and protein to foods by adding sauces, gravy, butter, cheese, peanut butter, cream, and nuts.
- Drink fluids between meals rather than with meals. Drinking during a meal can make you feel full too quickly.
- Choose nutritious drinks, such as milk, milkshakes, and juices.
- Ask family members or friends to prepare foods when you are too tired to cook. Ask them to shop for groceries or buy precooked meals.
- Try to eat in pleasant surroundings and eat meals with family or friends.
- Eat food that is cold or at room temperature to decrease its odor and reduce its taste.
- Ask your doctor about ways to relieve other gastrointestinal symptoms, such as nausea, vomiting, and constipation.
- If your sense of taste is diminished, try adding spices and condiments to foods to make them more appealing.
- Try light exercise, such as a 20-minute walk, about an hour before meals to stimulate your appetite. Consult your doctor before starting an exercise program. Exercise also helps maintain muscle mass.
- Meet with a registered dietitian (RD) for additional advice on meal planning.
Constipation is a very common problem for our patients. Pain medications, chemotherapy drugs, erratic diets, pain, and a patient's emotional state may all contribute. Management of this problem is simple but usually requires continuous rather than intermittent treatment. Of course, eating a diet rich in fresh fruits, vegetables, fiber-containing cereals, prune juice, drinking enough amount of water, and getting daily exercise within your limitations often will result in regular bowel function. Below is a standard prescription that works well for most people that result in a regular bowel movement (BM).
- Stool Softener for example Colace (Docusate Sodium), Senokot-S and Surfak (Docusate Calcium) -Start by taking two capsules daily, every day, then adjust your dose gradually up or down until you have a good BM every 1-2 days. Some patients will need as many as 4-5 capsules twice daily. If bowels get loose, stop taking capsules until bowels firm up, and then start again at a lower dose.
- Milk of Magnesia (MOM) or Haley's MO -Take two tablespoons twice daily if you didn't have a good BM the day before. Some people will need this frequently, others rarely or never.
- Dulcolax tablets or suppository -This may be tried once or twice if there are no results from Step 1 and Step 2. These should be used sparingly.
- Lactulose, Chronulac, Magnesium Citrate, and Fleet’s Enema - these should only be taken by Doctor's Orders.
The following treatment plan is primarily for diarrhea caused by chemotherapy. Please talk with your doctor about treatment for other causes.
- Avoid milk, dairy products, and citrus juices (citrus irritates stomach linings). In addition, fatty foods (hot dogs, pizza, bacon, fried foods, and gravies), foods that contain lots of fiber (whole wheat bread, bran, nuts, popcorn, seeds) or foods containing caffeine (coffee, tea, colas, Mountain Dew, chocolate) can also make diarrhea worse.
- Do drink plenty of clear liquids, especially water, Gatorade (which can be diluted to half-strength), V8 and apple juice. It is often helpful to limit your diet to clear liquids for 12-24 hours, or until diarrhea stops, and then gradually add clear soups, bread, and crackers. Once these stay down you can gradually resume your normal diet.
- Eat small meals five to six times a day instead of three large meals and replace fluid loss with liquids between meals.
- Imodium AD - This over-the-counter caplet is useful to slow down diarrhea. Take two caplets (4 mg) after the first loose stool followed by one caplet (2 mg) after each subsequent loose stool but no more than eight caplets in twenty four hours (16 mg). Stop taking Imodium when bowel movements are down to one or two daily, or when they begin to firm up. You can make yourself constipated if you take Imodium past this point.
- Lomotil - This prescription medication is a little more potent than Imodium. If Imodium is ineffective, call the nurse for a prescription.
- If the above measures are ineffective, you need medical evaluation and more potent medications. Patients who become dehydrated from rapid fluid loss may need hospitalization. Call your nurse to come to the office for evaluation and treatment. If it is after office hours or on a weekend, you may need to go to the nearest emergency room for proper evaluation and possibly admission to receive intravenous fluid for hydration.
4. Mucositis (mouth sores)
Mucositis, or stomatitis, is a medical term that refers to the mouth sores and inflammation caused by some chemotherapy drugs. Some drugs, especially 5-FU and methotrexate, frequently cause this. Others, such as Taxol, Taxotere, Adriamycin, and Doxil, may cause mucositis in some patients. The severity of mucositis varies considerably. Some patients with mild sores simply have discomfort when eating. More severe mucositis can prevent any oral intake and lead to dehydration. Since the same chemo drugs that cause mucositis may cause diarrhea, patients with both of these problems may become dehydrated quickly. The following treatments may help to ease the discomfort of mucositis. However, once mucositis has started it simply takes time (a few days) to resolve.
- Keeping ice in your mouth during an infusion of 5-FU can reduce the severity of mucositis.
- Rinse your mouth frequently with a solution of two teaspoons baking soda in a cup of water. This should be repeated every 2-4 hours. Be sure to spit it out; do not swallow it.
- Avoid citrus juices, over-the-counter mouthwashes, hot or very cold foods, and spicy or salty foods.
- "Ron's Rum" or “Magic Mouthwash” - this prescription anesthetic mouthwash can ease pain and allow you to eat or drink after using it.
- If you see white patches in your mouth you may need a special antifungal for yeast (thrush) infection.
- If you cannot eat or drink, call the nurse for instruction or to be seen by a doctor. You may need to get intravenous fluids or more potent pain medications
5. Neutropenia (Low WBCs)
Most chemotherapy drugs can cause a decrease in the white blood count, or neutropenia. When a patient's white blood count is low there is increased susceptibility to infection. Moreover, an infection, once started, can spread rapidly because the body's defenses are decreased. The white blood count generally reaches its lowest point, or nadir, between one and two weeks after the chemotherapy is given, and then gradually rises toward normal. This is why doctors often check blood counts between cycles of chemotherapy and before the next cycle is given.
It is important to contact a nurse or doctor if you develop temperatures to 101 degrees, sweats, shaking chills, or other signs of infection between cycles of chemotherapy. We will usually have you come to the office to check blood counts and be evaluated by our oncologist. Depending on the blood counts and physical examination, a decision will be made whether to admit to a hospital, treat as an outpatient, or simply observe.
When a patient has a low white blood count, or if the patient's doctor expects this to occur after chemo, the patient is often started on Neupogen (GCSF), or Leukine (GMCSF) shots, which stimulate cells in the bone marrow to produce more white blood cells. These drugs are generally given for several days in a row at the nadir. Neulasta (pegfilgrastim) is another drug that represents a longer acting form of Neupogen and is given subcutaneously once every 3 weeks. Patients are generally started on antibiotics when white blood counts are low. Cultures of blood, urine, catheters, ports, or any infected sores may be done to help direct antibiotic therapy. If a patient is very ill or if the white blood count is very low the doctor will often advise admission to a hospital. For more details, please refer to the Q&A “Will my treatment plan put me at elevated risk of infection?”
Anytime you have a medical emergency, call 911 for assistance. If you simply have a concern or question for the physician that cannot wait until office hours, please call our office and listen carefully to the greeting which will direct you to the after-hours number. This service is available 24 hours a day, 7 days a week. The following symptoms are of great concern and require urgent attention immediately.
- Temperature of 101° or greater.
- Severe shortness of breath.
- Chest pain.
- Severe abdominal pain.
- Vomiting or diarrhea that lasts longer than 24 hours without relief from medicine.
- Painful sores that develop in your mouth and interfere with eating.
- Severe pain or discomfort that does not go away with usual pain medications.
Infection is defined as the process by which germs enter a susceptible site in the body and multiply, resulting in disease. Infection is a common problem in persons with cancer. Persons with cancer are at increased risk of infection as a result of:
- The underlying disease, for example leukemia or lymphoma affects the body's normal defense against infection.
- Side effects of treatment that interfere with the body's normal defense against infection.
The body's defense against infection includes:
Organs that are part of the immune system:
Skin and mucous membranes: The skin is the largest organ in the body and our first line of defense against infection. Any break in the skin is a potential site of infection.
- For example: Surgical site or site where the IV catheter is inserted is susceptible to infection.
- Thymus: Is a small glandular organ that is situated behind the top of the breastbone. It consists mainly of lymphatic tissue and serves as a storage place for T cells of the immune system
- Spleen: Is located in the upper left side of the abdomen. It has many infection fighting functions such as filtering out foreign organisms, removing old or damaged cells, helping form some types of white blood cells. The spleen can be removed if damaged but this may lower your resistance to infection.
- Lymph nodes: Are small collections of infection fighting cells that exist in chains along the course of the large blood vessels of the body. There are hundreds of lymph nodes throughout the body. These nodes filter lymph fluid, removing foreign substances such as bacteria that get trapped in their web-like structure. Then the infection fighting cells such as macrophages, antibodies, and T cells can destroy them.
- Bone marrow: Located in the center of the bones of the body particularly in the bones of the spine, ribs, breast bone, pelvis and upper arms and legs. It is the principal site for production of blood cells.
- Infection fighting cells of the immune system: Particularly the white blood cells (WBC). There are five main types of WBC's - lymphocytes (B and T cells), macrophages, basophils, eosinophils and neutrophils. When your white blood cell count is low there is an increased risk of infection.
The level of risk for infection depends on several factors:
- How low the WBC count falls?
- How long the WBC count is low?
- Which type of WBC is low?
- One measure of risk for infection is the absolute neutrophil count (ANC). The ANC is calculated by multiplying the total WBC by the percent of neutrophils (also called segmented neutrophils, segs, polymorphoneucleated cells or PMNs, polys).
- Total WBC x % neutrophils = ANC
* Neutrophils may be reported as segs & bands (a band is slightly less mature form of a seg). In this case add the % of segs to the % of bands then multiply by the total number of white blood cells.
(% bands + % segs) x Total WBC = ANC
|Risk of infection based on Absolute Neutrophil Count (ANC)|
ANC greater than 1500
ANC less than 100
No increased risk of infection
Slight increase in risk of infection
Moderate increase in risk of infection
High risk of infection
Extremely high risk of infection
Since we know drugs and diseases that can decrease the normal body defenses against infection, and the types of infection likely to occur in patients, most types of infection are potentially preventable and often treatable.
When your white blood cell count is low you may NOT have the usual signs and symptoms when developing an infection such as:
- Pus formation (at the site of an injury or incision)
- Nasal drainage (from a sinus or respiratory infection)
Therefore, it is extremely important to be alert to any change in how you feel and report and discuss what you are feeling with your doctor or nurse.
Things you can do to manage infection:
Learning needs: There is some important information that you need to learn about infection and how infection relates to the treatments you are receiving. This includes:
- What to do to decrease your chances of infection.
- Signs and symptoms of infection
- When infection is most likely to occur
- How to manage infection if it does occur.
Your health care provider will tell you when you are getting treatment that may cause your white blood cell count to be lowered. Additional information to ask is when the white blood counts will most likely be at its low point (nadir). This will give you a gauge as to when your body is less likely to be able to fight off infection.
Prevention of infection: Infection cannot be completely prevented. However, there are things you can do to decrease the risk of infection.
You are most susceptible to a bacterial infection about seven to 12 days after your chemotherapy infusion if your white blood cells are low. Most bacterial types of infection result from your body's inability to fight off normal bacteria present in your gastrointestinal tract or skin. Bacterial infection does not commonly result from being in a crowded place. However, types of viral infections such as colds and flu are common and are transmitted easily from other people.
To help decrease your risk of infection:
- In general, it is fine to go to public places. Avoid, if possible tightly crowded places during the height of the cold/flu season. Generally a mask will not offer much protection from infection, so it is better to avoid close contact with people coughing and sneezing.
Wash your hands often. For example:
- After frequent handshaking.
- Before preparing food to eat.
- After touching raw meat like chicken or steak.
- Before eating.
- After using the restroom.
- After changing a baby's diaper.
- After coming into direct contact with someone who is very young or very old.
- After touching animals such as dogs or cats.
- After sneezing and coughing especially if you used your hands to cover your mouth.
Wash your hands the correct way to minimize risk of infection:
- First, find a towel to dry your hands, a paper towel is better to use because you can throw it away (infection carrying germs can live on a wet cloth towel). Get the paper towel before you wash your hands to keep from touching the knob or container with your clean hands. Put the towel under your arm until you are ready to use it.
- Wet your hands with water. Warm water is best. Hot water can make your skin dry and itchy.
- Put soap on your hands. Liquid soap is better because germs causing infection can live on bar soap. Bar soap is fine to use as long as you dry it on a soap bar.
- Rub your hands together for 10 to 15 seconds or until all dirt is gone. To do a good job you need to wash in between your fingers, the back of your hands and your thumbs and under your fingernails. If you do not wash in all of these places, you may not remove all of the germs that can cause infection.
- Rinse your hands with warm water. Make sure to rinse between your fingers and under rings. If you do not get all of the soap off, it could cause the skin to itch.
- Dry your hands with a soft paper towel. Pat your hands dry - rubbing might damage your skin. If there is a blow dryer to dry your hands, push the button with your elbow.
- Use the towel to turn off the water. (You don't want to get germs from the water faucet back on your clean fingers).
- Keep your body clean by showering or bathing daily. If your skin becomes dry, use lotion or oil to soften your skin and prevent cracking.
- Avoid injury, even small cuts or tears in the skin could be a susceptible site for infection.
- Wear shoes or slippers to protect your feet from injury and/or infection.
- Keep your mouth clean by brushing your teeth twice daily. Use soft toothbrush and mouth rinses without alcohol. Do not use floss. Check with your healthcare professional before having any dental work done.
- To help treat or prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda or 1/2 to 1 teaspoon of salt mixed with 8 ounces of water.
- Avoid constipation and straining to have a bowel movement by using a medication that softens the stool ex. Colace (stool softener). Drink 2 quarts of fluid a day. Check with your health care professional before using laxatives or enemas.
- Wash hands, utensils, and surfaces with hot soapy water before and after food preparation, especially after preparing meat, poultry, eggs or seafood.
- Keep raw meat, poultry, eggs, and seafood away from ready-to-eat foods.
- Do not place cooked food on an unwashed plate where raw meat, poultry, eggs, or seafood has been to reduce risk of infection.
- Cook food well. Use a food thermometer to check the internal temperature. Cook meat until it is no longer pink and the juices are no longer clear. Cook eggs until they are firm. Bring sauces, soups, and gravies to a boil when reheating.
- Do not eat raw food such as sushi, Caesar salad or milk shakes made with raw eggs, until you complete chemotherapy and your blood counts have returned to adequate levels.
- Keep cold foods cold. Refrigerate or freeze foods that may spoil.
- Refrigerate leftovers within 2 hours and make sure the refrigerator temperature is no higher than 40ºF, and the freezer temperature is 0ºF.
- Never thaw food at room temperature; thaw food in the refrigerator.
- Don't pack the refrigerator too full - cool air needs to be able to circulate to keep food cold and safe.
- Thoroughly wash all fruits and vegetables.
- Do not change cat litter or clean up waste (urine or feces) from animals. Have someone else take this chore on during times of low WBC's when risk of infection is high.
- Avoid contact with reptiles such as snakes, lizards, and turtles because of the risk of salmonellosis.
- Avoid cleaning fish tanks because of possible exposure to Mycobacterium Marinum.
- Birds, especially if imported from other countries, should receive a clean bill of health from a veterinarian.
- Routine flower and vegetable gardening is permissible using some infection precautions. Strictly avoid an environment where mulch, hay, topsoil, etc. is being "pitched" or spread. Inhalation of environmental spores, particularly from moist, dark areas (e.g. compost piles) may lead to infection and should be completely avoided. (Aspergillus spores that are abundant in these areas and if they are inhaled can cause serious disease in the immunosuppressed person).
- Gloves should be worn for contact with dirt and soil and good hand washing after the gloves are removed is essential. If walking through areas where soil, dust and fungal spores may be found in the air cannot be avoided, wearing a mask is preferred.
- People at highest risk for infection should not drink water directly from lakes or rivers. If necessary boil water for 1 full minute to avoid cryptosporidium and other waterborne organisms. Use of a submicron personal-use water filter may reduce the risk of infection. Be advised that swimming can cause accidental ingestion of water and may increase the possibility of acquiring cryptosporidium, even in public swimming pools. Avoid situations that would permit the inhalation of environmental spores, particularly from moist, dark areas (e.g. compost piles, rotting leaves etc.). Again these are areas where Aspergillus spores are abundant and if they are inhaled can cause serious disease in the Immunosuppressed person.
- Hot tubs, saunas, and other communal baths are generally not recommended. Bacteria and other microorganisms thrive in warm water. However, if the immunosuppressed person is aware that the tub is adequately disinfected regularly as recommended then there is no contraindication to their use.
- Spelunking or cave exploration should not be done because of the infection risks associated with exposure to bat waste products.
Travel abroad: The risk of food and waterborne infections among immunosuppressed persons at highest risk of infection is magnified during travel to developing countries.
- Those who elect to travel should avoid foods and beverages that may be contaminated, particular raw fruits and vegetables, raw or undercooked seafood or meat, tap water, ice made with tap water, unpasteurized milk and dairy products, and items sold by street vendors.
- Foods and beverages that are generally safe from infection include steaming-hot foods, fruits that are peeled by the traveler, bottled (especially carbonated) beverages, hot coffee and tea, beer, wine, and water brought to a rolling boil for 1 minute. Treatment of water with iodine or chlorine may not be as effective as boiling but can be used when boiling is not practical.
- Prophylactic antimicrobial agents are not generally recommended for travelers, but your doctor may advise carrying certain medications with you. The effectiveness of these agents depends upon local antimicrobial-resistance patterns, which are seldom known.
- Check with your physician for decisions based upon your level of risk for infection and the region and duration of travel.
- Regular dusting, sweeping, windows, floor washing, bathrooms are okay to clean if you feel well. However, avoid cleaning or dusting areas where a lot of sediment can be aerosolized. Use common sense and avoid cleaning areas that have been untouched for years. Aspergillus lives in dust, especially in old building. Wear gloves for washing heavily soiled areas and commodes.
- In general, it is wise to avoid construction/renovation areas because of the possibility of aerosolized yeast or mold in the dust. If it is unavoidable an immunosuppressed person can reduce the risk of infection by wearing a particulate respirator (mask - NIOSH approved N95 respirator) and fitting it tightly to his face.
There are a few occasions when a mask (NIOSH approved N95 particulate respirator) is appropriate. It is appropriate if the immunosuppressed person must go into a construction/renovation area, or when exposed to heavy puffs of dust or debris. Additionally, if required to have close contact with another (children, adults, etc.) that is ill with a respiratory infection (common cold, flu, and childhood illness) a mask will reduce the risk of acquiring the infection.
Your doctor or health care provider may prescribe or suggest:
The following medications may be given after each cycle of chemotherapy to prevent your white blood cells from falling too low and/or for too long.
- Filgrastim (Neupogen®)
- Peg - Filgrastim (Neulasta®)
- Epoetin Alpha (Procrit)
- Darbepoetin (Aranesp)
The following are antimicrobial medications that may be prescribed to prevent specific infections that are common when the immune system is suppressed by chemotherapy and other medications.
- Sulfamethoxazole – trimethoprim
Other antibiotics or antimicrobials are used to treat specific types of infection as needed.
When to call your doctor or health care provider about the possibility of infection:
Call immediately if you have:
- A temperature greater than or equal to 100.5°F (38ºC). Check with your health care provider, you may be instructed to call for temperature greater than or equal to 100°F.
- Chills (rigors) or shakes.
- Sudden onset of a new unexplained pain.
Call within 24 hours if you experience the following:
- Sore throat.
- Sores in your mouth.
- A white coating in your mouth, especially your tongue.
- Signs of a bladder infection.
- Burning with urination.
- Blood in your urine.
- Needing to urinate more frequently than normal.
The side effects of chemotherapy may prevent you from being able to drive after your chemotherapy session, even though you likely will be able to physically get behind the wheel of a car.
Fatigue, nausea, and vomiting are all common side effects that may affect not only your desire to drive, but your concentration and alertness, too. Vision changes - such as blurred or double vision - can also accompany chemotherapy. This side effect is less common than fatigue and stomach upset, but it can certainly affect your ability to safely drive.
If you are taking any pain medications, please remember that it is recommended that you do not drive while taking them. They can cause drowsiness, which can decrease your response time and even cause you to fall asleep at the wheel. It isn't worth the chance of hurting yourself or others.
If you find that you cannot drive yourself to and from chemotherapy sessions, you may want to consider taking a taxi, public transportation, or asking a friend to drive you. If none of those options work for you, contact your local American Cancer Society chapter who may be able to refer you to patient transportation services.
Talking to your doctor is the best course of action for determining if you are fit to drive after chemotherapy. He is knowledgeable about the side effects of your chemotherapy regimen and how treatments may affect your driving.
Follow-up cancer care involves regular medical checkups that include a review of a patient’s medical history and a physical exam. Follow-up care may include imaging procedures (methods of producing pictures of areas inside the body), endoscopy (the use of a thin, lighted tube to examine the inside of the body), blood work, and other lab tests.
Follow-up care is important because it helps to identify changes in health. The purpose of follow-up care is to check for recurrence (the return of cancer in the primary site) or metastasis (the spread of cancer to another part of the body). Follow-up care visits are also important to help in the prevention or early detection of other types of cancer, address ongoing problems due to cancer or its treatment, and check for physical and psychosocial effects that may develop months to years after treatment ends. All cancer survivors should have follow-up care.
During each visit, patients should tell their doctor about:
- Any symptoms that they think may be a sign that their cancer has returned.
- Any pain that bothers them.
- Any physical problems that interfere with daily life or are bothersome, such as fatigue; difficulty with bladder, bowel, or sexual function; difficulty concentrating; memory changes; trouble sleeping; and weight gain or loss.
- Any medicines, vitamins, or herbs they are taking and any other treatments they are using.
- Any emotional problems they are experiencing, such as anxiety or depression.
- Any changes in their family medical history, including any new cancers.
It is important to note that cancer recurrences are not always detected during follow-up visits. Many times, recurrences are suspected or found by patients themselves between scheduled checkups. It is important for patients to be aware of changes in their health and report any problems to their doctor. The doctor can determine whether the problems are related to the cancer, the treatment the patient received, or an unrelated health issue.
The frequency and nature of follow-up care is individualized based on the type of cancer, the type of treatment received, and the person’s overall health, including possible treatment-related problems. In general, people return to the doctor for follow-up appointments every three to four months during the first two to three years after treatment, and once or twice a year after that.
At these follow-up appointments, the doctor may recommend tests to check for recurrence or to screen for other types of cancer. In many cases, it is not clear that special follow-up tests improve survival or quality of life. This is why it is important for the doctor to help determine what follow-up care plan is appropriate. The doctor may not need to perform any tests if the person appears to be in good physical condition and does not have any symptoms. It is important for the patient to talk with the doctor about any questions or concerns related to the follow-up care plan.
When planning a follow-up care schedule, patients should consider who will provide the follow-up care and who will provide other medical care. They should select a doctor with whom they feel comfortable. This may be the same doctor who provided the person’s cancer treatment. For other medical care, people should continue to see a family doctor or medical specialist as needed.
Some people might not have a choice in who provides their follow-up care, because some insurance plans pay for follow-up care only with certain doctors and for a set number of visits. In planning follow-up care, patients may want to check their health insurance plan to see what restrictions, if any, apply to them.
It is an implantable device that makes it much easier to draw blood for tests and much safer to administer chemotherapy. It consists of a catheter (small flexible tube) that is placed in a large vein and connected to a “port” about the size of a quarter. The port is placed under the skin of your upper chest. Once inserted we recommend that an Infuse-a-Port not be removed until the likelihood of a recurrence of your cancer is minimal. We will arrange and make a referral to one of our qualified general surgeons, vascular surgeons or interventional radiologist for placement of this device. Infuse-a-Port should be flushed at least once every four to six weeks.
Your doctor and nurse will use several ways to see how well your treatments are working. You may have physical examinations and several laboratory as well as imaging tests performed on regular basis. Always feel free to ask your doctor about the test results and what they show about your progress.
Tests and examinations can tell a lot about how chemotherapy is working; however, side effects tell very little. Sometimes, people think that if they have no side effects, the drugs are not working, or, if they do have side effects, the drugs are working well. However, side effects are not a sign of whether the treatment is working or not since they vary so much from person to person, and from drug to drug.
Menopause is a normal stage in a woman's life. The term menopause is commonly used to describe any of the changes women experience either before or after she stops menstruating. Technically, the diagnosis of menopause is not confirmed until a woman has not had her period for six consecutive months.
During chemotherapy, women may have preliminary signs of menopause such as irregular menstrual cycles or her periods may disappear. Some medications used in chemotherapy may also cause damage to the ovaries, resulting in menopausal symptoms or menopause. Menopause may be immediate or delayed, permanent or temporary when triggered by chemotherapy. Unfortunately, there is no way to accurately determine how or when chemotherapy or other cancer treatments will affect your menstrual cycle. However, menopause is rarely a sudden response to chemotherapy. When chemotherapy treatments begin, you may notice some menopausal symptoms, but they are usually delayed for several months after treatment is started. This is natural.
Many pre-menopausal women retain or recover ovarian function and their periods return after treatment is completed. In such cases, the chemotherapy has not truly brought on menopause. Return of ovarian function may depend on the woman's age prior to treatment and the type of medication she received during treatment.
There is always a chance that you can get pregnant as long as you are menstruating. While on chemotherapy, your menstrual cycle may become irregular. As a result, you may never quite be sure where you are in your menstrual cycle and your period may take you by surprise. Some of your menstrual cycles may be non-egg producing, but you cannot rely on this. Even if your periods seem to have stopped, you should use a safe and effective method of birth control during and for 4-8 weeks after chemotherapy has ended.
The most common symptoms of menopause (whether chemotherapy-related or not) are hot flashes, emotional changes, sexuality changes, and weight gain. The symptoms will vary from person to person. There are treatments available to assist in managing these symptoms, but they must be supervised and prescribed by a doctor.
Therapeutic sperm banking, the process of storing sperm in a sperm bank before starting radiation or chemotherapy is an option available to any man - married or not - who is concerned about the possible side effect of infertility.
Sperm banks are facilities at a limited number of health-care institutions where sperm are frozen and stored in liquid-nitrogen-cooled refrigerators. Commercial sperm banks are available in some cities.
Before undergoing radiation treatments, patients are usually advised to collect specimens over at least two weeks to begin the sperm banking process. Specimens can be stored because the capacity of sperm to fertilize eggs does not change for an extended period of time.
There are costs involved with sperm banking - fees for freezing, storing and retrieving sperm for the donor. Costs vary among institutions, and some portions are covered by some insurance companies. Since most physicians want patients to start cancer treatment shortly after diagnosis, it is important to locate a sperm bank as soon as possible to begin the sperm banking process.
For more information about sperm banking talk with your physician, and/or a specialist in fertility treatment. The American Association of Tissue Banks in McLean, VA., also maintains a registry of U.S. sperm banks and can be reached at 1-800-635-2282.
Flu shots are given to protect against certain strains of the influenza virus, which cause the "flu." Flu shots are a good idea for anyone who is at high risk for becoming seriously ill from the flu. This includes elderly people and people with chronic diseases, such as cancer, in which the immune system may be compromised. The flu shot does not guarantee that you will not get the flu but if you do get the flu, it likely will be less severe.
Before proceeding, however, you should check with your doctor to be sure that there is no reason you should not get the flu shot.
Cancer clinical trials (also called cancer treatment studies or research studies) test new treatments for people with cancer. These can be studies of new types of chemotherapy, other types of treatment, or new ways to combine treatments. The goal of all these clinical trials is to find better ways to help people with cancer. We can arrange for a second opinion referral to a tertiary care facility close to home to explore their trials on-site.