Chemotherapy

Yes, everyone I've spoken with has a similar experience with chemo. I found that I could not concentrate and therefore reading was useless. Too bad, I love to read and learn - its exciting to learn by reading. Eating was not so hot either, my tasting ability was gone along with my appetite. So I ended up watching the clock tick, went for long slow walks. I improved physically as my body acclimated to the chemo. Then, I became much more active - reading, watching tv, walking, talking on the phone, checking out the internet, writing letters, and more.

Kathleen,

Congratulations on making the decision not to tackle fitness goals alone. There are a wide variety of fitness tricks and nutritional approaches that might be helpful, however many find that the best approach is often the one that considers (in no particular order):

1) Life/family responsibilities (i.e. your energy demands)
2) How regularly & intensely you trained before chemo
3) Resources ($, access to exercise equipment, facilities, etc)
4) Current energy levels and your energy cycles (i.e. good day vs bad day)

Because those variables can really impact how you approach slimming down, I'll include just a few exercise-based and nutrition-based notes.


Exercise
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* Get a journal and record snapshots of your general activities, nutrition and exercise. Journaling will keep you honest and enable you to, truly listen to your body. Speaking of snapshots, you may also want to take before photos and put them in your journal and wallet. They can be powerful motivators.

* Listen to your body and obey it. This really bears repeating. Pay close attention to not only how your body feels right after a workout but how it feels 1-2 days later as well! The journaling will help a lot, review it weekly.

* In the beginning, start with short, low to moderate intensity workouts, 20-30mins long. Do them only on your higher energy days. Avoid exercising on low energy days at first...consider making gentle stretches the most that you do on low intensity days. Some people find that they can only handle 10-15mins. That's ok. You might even try doing 2 short but vigorous workouts of 10-15mins, gradually increasing the length of workout by a few minutes and decreasing intensity before increasing intensity and length.

* As you progress (after a few weeks or so) you may want to try incorporating 1-2 more intense interval (burst) style workouts per week. They are a great way to help boost the metabolism without introducing some of the inflammatory effects that could potentially accompany lots of long workout sessions.

* If you are more of an enthusiast and are ready for it, very controlled interval training using a modified tabata scheme, could be a useful strategy, minding the caveats above. The Tabata scheme is based on 4 minute exercise cycles composed of 8 continuous, 30-second rounds of exercise, where you work as hard as you can for 20 secs and rest for 10 secs. Initially, 20 secs will probably be way too much. Consider the following scheme for progression:

Initial Stage => Modified Tabatas, w/ 8 rounds of 5-10 secs full-out exercise followed by 20-25secs break.

Progression => Add 2-5 secs of work every 1-2 weeks or as tolerated.

* If you choose to work with a trainer, make sure to find one that's sensitive to not only the inevitable energy swings but also the importance of balancing movement around joints (e.g. pushes and pulls are balanced) as well as moving in all planes.

Nutritionally
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* Especially in the beginning, try to train only when you're both rested and well nourished (eat ideally 1-2hours beforehand). Smoothies/Shakes are great for pre/post workout meals since it can be a bit easier to absorb the nutrients easier.

* Eat every 3.5-4hours (~4-6x per day) and Eat your largest meals earlier in the day and taper your meals as it gets later. Last meal should be the smallest, though still complete.

* Typical meals should include (low GI & fibrous carbs, lean complete proteins, good, higher omega 3 fats). Of course, avoid processed foods in favor of loading up on leafy greens and the like (organic is best)!

* Discuss _any_ supplementation (multivitamin/mineral, probiotics, fish oil, etc) with your doctor first.

* Try to avoid snacking within ~2 hours of bedtime. If you must, try to limit the damage by stocking the fridge and cupboards with fibrous, low GI/GL foods (glycemic index/glycemic load)

I'll close by encouraging you to remember to periodically add to your mental/spiritual toolkit for navigating the almost inevitable bumps along the road to your body transformation, it's often great to add an inspirational quote, story or song to your journal, on your journal review day (for example). Sorry if that was waay more than you were bargaining for, but I hope you'll find the info useful. Enjoy!!!

R-CHOP (cycophosphamide, adriamycin, vincristine and prednisone, with rituximab) is the standard front-line therapy for diffuse large cell lymphoma and older patients with mantle cell lymphoma. Hyper-CVAD ( a more intensive regimen of cyclophophamide, vincristine, and doxorubicin, alternating with cytosine arabinoside and methotrexate) is often used for younger patients who have mantle cell lymphoma or Burkitts lymphomas. Patients with follicular lyphomas may receive CVP (a gentler form of cyclophosphamide, vincristine and prednisone) with rituximab or receive single agent rituximab.

Rituxan is a useful drug for B-cell lymphomas. Most B-cell lymphomas express the B-cell marker protein CD20. Rituxan is a monoclonal antibody with specificity for B cell lymphomas expressing CD20. These include follicular, diffuse large cell, mantle cell and several other types.

There are a variety of physician preferences for following tumors during therapy, but the approach used in most clinical trials is a standard CT scan every other cycle of chemotherapy. There is increasing use of PET scanning, but this is experimental, expensive, and there is a high risk of getting misleading information from a PET that could result in inappropriate changes in therapy.

Cisplatin and alimta (pemetrexed) is a very reasonable adjuvant therapy, unless you had squamous type lung cancer. The choice of adjuvant therapy is an imprecise science, but the strongest evidence is for some regimen containing cisplatin, and avoiding pemetrexed in squamous cancer. Trials are underway to test the addition of bevacizumab to chemotherapy.

As with radiation, anti-oxidants in supplement form can interfere with many chemotherapy treatments but there is no evidence that the anti-oxidants found in whole foods are harmful (againnot dehydrated, concentrated versions of what was once a whole food). If your chemotherapy will decrease your infection fighting cells (as most do) then your doctor or nurse will likely tell you to avoid unpeeled fruits and vegetables and sushi. There are also some foods that should be avoided with specific chemotherapies and your oncologist or chemotherapy nurse can tell you what these are if any.

I did 2 rounds of In Vitro Fertilization prior to starting chemotherapy. The first round was not very successful which is why we did it twice. In the end we were able to freeze several embryos.

The way I made it through chemo was just by dragging myself in, and doing it. No special strategies or skills. But I will say that what I learned to be helpful along the way was the other patients. We shared snacks, boob jokes, a little about ourselves. I called them my chemo clic.

Of course part of getting through chemo is dealing with side effects. I had very few. But let me tell you about the couple I had and what I did:

I had a few mouth sores and my oncologist prescribed a mouth wash that worked beautifully. I’m sorry I don’t remember the brand name, but know that your onc can prescribe something more effective than the over-the-counters if you have this problem.

I became severely neutropenic (very low white blood cells). I had to stop chemo for a few rounds and then push and push my doctor to give me booster shots to raise my white cells. (I was in a clinical trial that would not allow the boosters). So the point I want to make here is that in my case, I wanted to get around the road block that was preventing me from resuming treatment, and the way I dealt with it was to be my own advocate.

I was dawg tired! Who isn’t when they go through treatments? The neutropenia definitely heightened the fatigue. I was not good at taking naps, but I would suggest that you do this. Sleep or at least rest in bed or out in the sun on a nice day. Let your house work go some. If you have anyone around to help with the jobs you’re used to taking on, have them help you. I graciously accepted the few meals friends made and I made enough food to have leftovers to save me cooking the next night.

What else helped was having someone to talk to who would just listen, not tell me what to do, not make judgment calls. I found very few friends who were this supportive. But I’d suggest gravitating toward the ones who are, and maybe getting in a support group of other survivors or patients on similar paths.

The nurse who prepares or educates the patient who will be receiving chemotherapy sets the tone for the patient and his experience regarding his initial chemotherapy experience and his chemotherapy course of treatment.

It is important to discuss the side effects of chemotherapy, the chemotherapy protocol, and how the body responds to chemotherapy, the importance of blood test, laboratory tests, diet, exercise and taking your temperature. The patient should be made aware that his team of healthcare professionals will be monitoring him to see how he is feeling and if he is showing any side effects from his chemotherapy treatment.

The patient should be encouraged and know if he has any questions or appears to have any side effects from the chemotherapy at home or on the outside the chemotherapy setting to call and to speak to someone regarding his care.

I always say never assume that a simple nosebleed, is a simple nosebleed. One must speak to a healthcare professional on his team regarding possible side effects.

Furthermore, the nurse should inquire if the patient lives alone, what support systems are in place? What type of work does he do and how will chemotherapy affect his quality of life.

Here are some frequent questions that patients have asked me before they started chemotherapy.
1. What is chemotherapy?
2. Will this chemotherapy work with my cancer? Will it cure me?
3. Am I going to die?
4. How did this happen to me? Why did this happen to me?

I have found the first few questions from patients are more emotional questions. Because the patients are concerned about survival and what will be the outcome.

After I address these emotional concerns about their disease process, then other questions come up:
How long is the course of my chemotherapy therapy?
What are the side effects of the medications?
What will you give me for me nausea?
What can I eat or cannot eat during my chemotherapy day or after?
Does my hair fall out? When will my hair start to fall out?
How long does the infusion chemotherapy take?
What oral chemotherapy do I take? How is that different from an infusion?
What are pre-treatments?
What do I have to do the day before chemotherapy or after my chemotherapy treatment?
Does anything happen while I am receiving chemotherapy?
What do I need to bring to my appointment?
Will my treatment be painful?
Where will I have my treatment?
What will happen when I arrive for my chemotherapy?

At this time the nurse should check to see how well the veins could be access for chemotherapy administration. Perhaps the patient does not have good access and may need to have a port put in place.

Other information that should be included regarding chemotherapy education is:

- Sexuality
- Methods of adherence regarding chemotherapy and medications that are part of the chemotherapy protocol.
- Check to see if the proper test are ordered before the patient under goes chemotherapy
- Know that the patient or their family most likely has been seeking information pertaining to the chemotherapy and the cancer disease process though social media.

Before any chemotherapy treatment a nurse must discussed with a patient potential complications that may occur when receiving an infusion. The nurse must do it in a manner that it is not alarming to the patient, but the patient is aware that they must seek the nurse’s attention if something should occur.

I tell my patients, if they feel different while they are receiving the infusion, they must tell someone, before the infusion progresses. Do not assume that the feelings that they are having are normal. Let the nurse make the nursing judgment.

I explain to my patient’s if they feel:
• Uneasiness or agitation
• Abdominal cramping
• Itching
• Chest tightness
• Light headed or dizziness’
• Chills
• Back pain
• Face turning red-flushed
• Nausea
• Difficulty speaking
• Burning or an uncomfortable feeling at the infusion site.

During the infusion, the nurse also must observe and ask the patient “How are you feeling?” while they are receiving the chemotherapy for potential reactions to the chemotherapy infusion as well.

If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy. These tests may include CT scans, bone scan, MRI, X-rays, laboratory studies, among others. If these tests show that the cancer is growing or that the cancer is showing up in new areas then that may signal a time when the chemotherapy needs to change. Chemotherapy may also change if it is causing too many side effects and problems for you.

We consider reducing the dose of chemotherapy when there are either laboratory studies that are outside a safe range or when side effects become too troublesome for our patients. Chemotherapy may be reduced, for example, for low blood counts. Also, it may be reduced in the setting of abnormal liver or kidney function tests. Sometimes reducing the dose is not safe enough and your doctor may have to hold the treatment for a week or more. Often reducing or holding a dose of chemotherapy will allow you to be treated safely at a future date.

During chemotherapy we hope to see an improvement in symptoms, if you are having any, within days or weeks of treatment. We expect to see changes on scans (for example, CT scans, X-rays, bone scans) within weeks of beginning treatment. Most often, we would recommend looking at scans within 6-8 weeks after starting chemotherapy. Sometimes the interval is related to how often you have the chemotherapy. For example, if your treatment is every 3 weeks then you may have scans at 6 or 9 weeks and if the chemotherapy is every 4 weeks then you may have scans in 8 or 12 week intervals. If the drug is working then we would expect to see tumors shrinking or staying the same size. If the drug is not working as well as we would like then we may see tumors getting larger or new tumors showing up on the scans.

Both oral and IV chemotherapy can be highly effective strategies for the treatment of breast cancer and which drug your doctor recommends may be related to the timing of treatment, what prior treatment you may have had, what type of breast cancer you have and patient preference. For metastatic breast cancer, one widely used drug is oral capecitabine (Xeloda). Another oral drug we use frequently for metastatic HER2+ tumors is a drug called lapatinib (Tycerb). The vast majority of the drugs we use are IV and many of them have been used for years; others are newer IV drugs (eribulin, ixabepilone, for example) and all have proven effectiveness. Sometimes, practical reasons may dictate whether oral or IV medications are used. If someone has a problem swallowing or taking pills then we use IV drugs and if someone has a preference for taking pills for convenience then we certainly take that into consideration.

In my opinion available scientific evidence does not suggest a benefit to chelation treatment for patients with cancer and safety is an important factor to consider. Some laboratory studies have suggested that agents that chelate copper or iron may affect cancer cells or the formation of tumor blood vessels but there is no robust evidence for clinical benefit with chelation. Chelation therapy also may have safety concerns. Chelation therapy may produce toxic effects, including kidney damage, irregular heart beat, nausea, vomiting, diarrhea, and temporary lowering of blood pressure. Since the therapy removes minerals from the body, there is a risk of developing low calcium levels (hypocalcemia). The possible interactions between chelation therapy and chemotherapy and other prescription or over-the counter medications are not well known.

Patients with stage IV NSCLC are first treated with platinum chemotherapy which is a platinum drug (either carboplatin or cisplatin) plus another drug (Gemcitabine, Paclitaxel, Docetaxel or Alimta). At some point, unfortunately, patients will progress and their tumor will grow after the first type of chemotherapy is given. Generally at that point, a second line drug is used and the platinum doublet is abandoned.

There are three approved second line drugs (Tarceva, Alimta, Docetaxel) for NSCLC but their use is dependent on what a patient got in the first line. For instance, if a patient received Carboplatin and Alimta as a first line regimen, then the second line possibilities would be Tarceva or Docetaxel. Sometimes the drug Gemcitabine is also offerred. Unlike first line therapy, second line therapy is generally just one drug, not two. Response rates (the percentage of patients whose tumors shrink) is lower in the second line (only 10 to 15% of patients' tumors will shrink) depending on the patient the drug used. While those numbers are small, there is ample data that patients who go on to receive a second line drug live longer than those that don't receive any second line drug.

The majority of cases of ovarian cancer (approximately 75%) are diagnosed at stage III or IV (spread of cancer outside the ovaries and into the abdominal cavity or beyond). The primary difference is in prognosis. The percent of women with stage I ovarian cancer who are alive 5 years after diagnosis is around 83-89%. For women with stage II ovarian cancer, that number drops to 65-70%. For women with stage III, it drops to 32-45%; and for stage IV cancers, the number of women alive 5 years after their diagnosis is less than 20%.

The primary treatment for all stages of ovarian cancer is surgery. After surgery, chemotherapy is recommended for most women, regardless of stage.