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What is cancer?

The body is made up of many types of cells. These cells grow and divide in a controlled way to produce more cells as they are needed to keep the body healthy. When cells become old or damaged, they die and are replaced with new cells.

However, sometimes this orderly process goes awry. The genetic material of a cell can become damaged or changed, leading to mutations that affect normal cell growth and division. When this happens, cells do not die when they should and new cells form when the body does not need them because the growth of cells is no longer a controlled event which is the defining feature of cancer. The extra cells may form a mass of tissue called a tumor. A tumor may be benign (non-cancerous) or malignant (cancerous). Cancer cells can spread to other parts of the body through the blood and the lymphatic system which is called metastasis.

Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. Most cancers are named for the organ or type of cell in which they start – for example, cancer that begins in the colon is called colon cancer; cancer that begins in the breast is called breast cancer. If the cancer spreads to another site it is still called the name of its origin – for example, breast cancer that spread to the liver is called metastatic breast cancer.

Cancer types (based on the original site of the mutated cell) can be grouped into broader categories. The main categories of cancer include:

  • Carcinoma – cancer that begins in the skin or in tissues that line or cover internal organs.
  • Sarcoma – cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue.
  • Leukemia – cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood.
  • Lymphoma and myeloma – cancers that begin in the cells of the immune system.
  • Central nervous system cancers – cancers that begin in the tissues of the brain and spinal cord.

How did I get cancer?

The reason why people develop cancer is not well understood. In most cases the cause is unknown or “idiopathic”. There are some known risk factors that contribute to cancer development, the most important of which is smoking which contains over 200 known carcinogens (materials that can cause cancer in certain people), but many are still undiscovered. We do not know why some people who are exposed to a carcinogen get cancer and others do not. The length and amount of exposure are believed to affect the chances of developing a cancer. Your genetics (genes inherited from you parents) also likely play an important role in whether an individual develops cancer. Finally, increasing evidence suggests that dietary factors, life style and nutritional status may play a role in development of certain cancers as well.

What are the different types of cancer treatments?

Which therapy is recommended to you is based on several factors, including the specific features of your cancer; your overall health; and whether the treatment is to cure your cancer, keep your cancer from spreading, or to relieve the symptoms caused by cancer.

The treatment of cancer involves one or more of the following modalities: surgery, chemotherapy, radiation therapy, hormonal therapy targeted therapy and biological therapy.

One or more of the aforementioned treatment modalities may be recommended as the most effective way of treating a cancer. Increasingly, it is common to use several treatment modalities (“multi-modality therapy”) together or in sequence with the goal of preventing a recurrence of the cancer and improve the probability of cure.

Surgery

Surgery is performed for the diagnosis, staging, and treatment of cancer. Importantly, some cancers cannot be removed by surgery because they have spread beyond an area or metastasized.

For those tumors that can be removed, a surgeon will typically remove it and adjacent tissue/lymph nodes. Information obtained from surgery can contribute to the staging of the cancer, the likelihood the cancer will recur and whether other treatment modalities will be required.

Chemotherapy

Chemotherapy is a drug or combination of drugs that attack cancer cells. This modality is used by a medical oncologist/hematologist. Typically, treatment is administered through a vein, injected into a body cavity, or delivered orally in the form of a pill.

Unlike surgery or radiation therapy in which the area treated is small or localized. Chemotherapy circulates in the blood to other parts of the body where the cancer cell may have spread but is not yet seen by the naked eye or it is readily apparent.

More than half of all people diagnosed with cancer receive chemotherapy to improve the likelihood of cure, alleviate symptoms and/or prolong their life enabling patients to enjoy full and productive lives. Importantly, many side effects that were once associated with chemotherapy are now easily prevented or controlled, allowing many people to work, travel, and participate in many of their other normal activities while receiving treatment.

Radiation Therapy

Radiation therapy uses high-energy rays to damage or kill cancer cells. This modality is used by the radiation oncologist. Like surgery, radiation therapy is a local treatment directed at a specific area in the body. It is used to shrink or eradicate visible tumor or microscopic (too small to see by the naked eye) cancer cells. Radiation therapy may be externally or internally delivered. External radiation delivers high-energy rays directly to the tumor site from a machine outside the body. Internal radiation is called brachytherapy and involves the implantation of a small amount of radioactive material in or near the cancer. Radiation may be used to cure or control cancer, or to ease some of the symptoms caused by cancer. Sometimes radiation is used alone or is part of the multimodality treatment plan.

Hormonal Therapy

Naturally occurring hormones in the body such as estrogen and testosterone may stimulate the growth and spread of breast and prostate cancer, respectively. Hormonal therapy involves

drugs that block hormone production or change the way hormones work or surgical removal of an organ that secrete hormones, such as the ovaries or testicles. Hormonal therapy can be a highly effective way to treat these hormone sensitive cancers. This form of therapy attacks cancer cells throughout the body.

Targeted Therapy

Targeted therapy is the latest form of cancer treatment. It is designed to treat only the cancer cells and minimize damage to normal, healthy cells. Cancer treatments that “target” cancer cells may offer the advantage of reduced treatment-related side effects and improved outcomes.

Conventional cancer treatments, such as chemotherapy and radiation therapy, cannot distinguish between cancer cells and healthy cells. Consequently, healthy cells are commonly damaged in the process of treating the cancer, which results in side effects. Chemotherapy damages rapidly dividing cells, a hallmark trait of cancer cells. In the process, healthy cells that are also rapidly dividing, such as blood cells and the cells lining the mouth and GI tract are also damaged. Radiation therapy kills some healthy cells that are in the path of the radiation or near the cancer being treated. Newer radiation therapy techniques can reduce, but not eliminate this damage. Treatment-related damage to healthy cells leads to complications of treatment, or side effects. These side effects may be severe, reducing a patient’s quality of life, compromising their ability to receive their full, prescribed treatment, and sometimes, limiting their chance for an optimal outcome from treatment.

Biological Therapy

Biological therapy is referred to by many terms, including immunologic therapy, immunotherapy, or biotherapy. Biological therapy is a type of treatment that uses the body’s immune system to facilitate the killing of cancer cells. Types of biological therapy include interferon, interleukin, monoclonal antibodies, colony stimulating factors (cytokines), and vaccines.

Complementary therapy

Complementary medicine (CM) represent treatment that may be given concurrent or following conventional therapy such as chemotherapy. Gentle therapies such as massage, relaxation techniques and other “healing” therapies play a significant role is disease related symptoms as part of a palliative care program. Complementary medicine is also called holistic or integrative medicine. Some patients find relief of pain, anxiety and nausea. CM is not alternative medicine which seeks to replace conventional therapy rather CM is integrated into proven conventional therapies.

Types of CM:

Sensory therapy (based on the 5 senses): Aromatherapy, music therapy, massage, therapeutic touch, Reiki, reflexology, acupuncture

Cognitive therapy: Visualization, hypnotherapy, prayer, meditation, deep breathing/relaxation, biofeedback, journaling, support groups.

Physical therapy: Exercise, yoga

About your cancer

  • What is the stage of my cancer?
  • Is there anything special about my cancer that makes my prognosis better or worse?
  • Do you commonly treat my form of cancer?
  • Can the cancer be cured or controlled?
  • What are my treatment options?
  • What risks or potential side effects are associated with each treatment?
  • What research studies (“clinical trials”) are available?
  • How long will I receive treatment, how often, and where?
  • How will it be given?
  • How and when will I know if the treatment is working?
  • What are the names of all the drugs I will be taking?
  • Are there any resources or Web sites you recommend for more information?

Tests

  • What types of lab tests will I need?
  • Can my cancer be followed by a blood test (tumor marker)?
  • Will I need x-rays, CT scans, PET/CT scans or MRIs and if so, when?
  • Can you explain the results of my complete blood count (CBC)?
  • Are there tests for the genetic make-up of my cancer?
  • Will I benefit from having my cancer evaluated for its genetic make-up?

Side Effects of Treatment

  • What possible side effects should I prepare for (for example hair loss, neuropathy, nausea, vomiting, diarrhea, allergic drug reactions or low blood counts) and when might they start?
  • Will they get better or worse as my treatment goes along?
  • How can I prepare for them or lessen their impact?
  • Are there treatments that can help relieve the side effects? What are they? Do you usually recommend or prescribe them?
  • Is there a certain diet or supplement that is recommended while receiving chemotherapy?
  • Will I require blood transfusions? Why?
  • How can I best monitor myself for complications related to either my disease or my treatment?
  • Will my type of chemotherapy put me at risk for a low white blood cell count and infection?
  • Can I help protect myself against infection right from the start of chemotherapy, instead of waiting until problems develop?
  • Am I at special risk for infection?
  • How long will I be at risk for infection?
  • What should I do if I have a fever?

Daily Activities

  • How will my cancer treatment affect my usual activities?
  • Will I be able to work?
  • Will I need to stay in the hospital?
  • Will I need someone to help me at home?
  • Will I need help taking care of my kids?\
  • Are there any activities I should avoid during my chemotherapy?

What to Expect After Treatment

  • What kind of lab tests will I need?
  • How frequently should I get those lab tests?
  • What types of x-rays and scans will I need?
  • How often do I need to come in for checkups?
  • When will you know if I am cured?
  • What happens if my disease comes back?

Chemotherapy is a drug or combination of drugs that attack cancer cells. This modality is used by a medical oncologist/hematologist. Typically, treatment is administered through a vein, injected into a body cavity, or delivered orally in the form of a pill.

Unlike surgery or radiation therapy in which the area treated is small or localized. Chemotherapy circulates in the blood to other parts of the body where the cancer cell may have spread but is not yet seen by the naked eye or it is readily apparent.

More than half of all people diagnosed with cancer receive chemotherapy to improve the likelihood of cure, alleviate symptoms and/or prolong their life enabling patients to enjoy full and productive lives. Importantly, many side effects that were once associated with chemotherapy are now easily prevented or controlled, allowing many people to work, travel, and participate in many of their other normal activities while receiving treatment.

When is chemotherapy used?

Chemotherapy is used in five different ways:

  • “Adjuvant therapy” is chemotherapy given after surgery, either alone or with radiation (or another type of therapy), and that is designed to kill microscopic cells that have metastasized but are not seen by the naked eye.
  • “Neoadjuvant chemotherapy” is used prior to surgery to shrink a tumor, sometimes in conjunction with radiation therapy.
  • “Primary therapy” is used alone when leukemia or lymphoma is present and in the management of other cancers when cure is not possible to control symptoms, improve quality of life and prolong life.
  • “Induction chemotherapy” is the initial or first therapy provided before a more definitive therapy. For instance, in the management of some lung cancers, chemotherapy may be given first (induction) followed by either surgery or radiation therapy.
  • “Combination chemotherapy” implies the use of two or more chemotherapeutic agents, allowing for each medication to enhance the action of the other and/or attack the cancer in a different way.

How is chemotherapy administered?

Chemotherapy can be given in several different ways:  intravenously (into a vein), by mouth, through an injection, or applied to the skin. The type of chemotherapy delivery will depend on the type and stage of a cancer.

Chemotherapy delivered intravenously is provided by a small IV needle in the arm or hand, through a large catheter, port, or pump. A catheter is a soft, thin, flexible tube that is placed in a large vein in the body. It remains in place as long as necessary. Sometimes the catheter is attached to a port, which is a small round plastic or metal disc placed under the skin and a common preferred route for chemotherapy administration. The port stays in place as long as necessary. A pump can be used to control how fast the drugs go into the catheter or port. An external pump remains outside the body. A peripherally inserted central catheter (PICC) is inserted into a vein in your arm and threaded to the deeper, central veins.

An intrathecal catheter delivers chemotherapeutic drugs directly into the spinal fluid. An intracavitary catheter (IC) is placed in the abdomen, pelvis, or chest.

What is a “cycle” and what is a “cycle day”?

Chemotherapy is typically administered on a fixed schedule and at a specified dose otherwise it could be less efficacious and/or may produce severe, potentially catastrophic side effects. You will typically be given a calendar to retain for your records. In it your treatments days should be specified as well as office visits and necessary testing. It considers each day in a 28 consecutive day time period as numbered (1, 2, 3, and so forth). Treatment is typically given in numbered cycles (1, 2, 3 and so forth) every 7, 14, 21 or 28 days. Thus, a treatment may be given and repeated on “cycle day” #1 and #8 in a 21 day (3 week) treatment “cycle”.

Let’s take another example: FOLFOX is a chemotherapy regimen used in gastrointestinal cancer. It is administered over a 2 day period via an external pump. Treatment is repeated every 14 days. Therefore, treatment is given every cycle day #1 and #2 of a 14 day treatment “cycle” which is repeated over and over until the desired number of cycles have been administered.

Does chemotherapy hurt?

Delivering the chemotherapy into the body does not usually hurt. However, some intravenous drugs may give patients a temporary burning or cold sensation. Patients will be told beforehand if this is expected to happen by your infusion center nurse. If pain does develop this may signify a problem such as a drug leaking out of the vein in the tissues (extravasation) and you should notify your physician or nurse immediately.

Why would chemotherapy require hospitalization?

Most chemotherapy drugs can be given in an outpatient office. However, if the chemotherapy drug or regimen requires special medical supervision or the schedule does not permit office administration then the patient may need hospitalization.

What about work and staying active during chemotherapy treatment?

The level of activity during chemotherapy depends on the type of cancer and the patient’s response to the treatment. Many cancer patients work and maintain normal activities during chemotherapy. Your physician at OC Blood & Cancer Care will typically discuss your level of activity prior to, during and after therapy.

Can regular foods and drink, such as alcohol, be taken during chemotherapy?

Patients may tolerate chemotherapy better by eating a light meal before and after treatment. Increasing fluid intake before, during, and after chemotherapy by two to four glasses of water daily is usually encouraged. One cocktail or glass of wine in a day will typically not be harmful. However, patients should specifically ask their doctor about the use of alcohol.

Do any medications interfere with chemotherapy?

Patients should talk to their doctor about all medications (including over-the-counter medications, supplements, vitamins, herbal products or complementary cancer therapies) used before starting or during chemotherapy treatment. Some types of medications may interfere with chemotherapy, including blood thinners such as Coumadin, hormones, antibiotics, cough medicine, vitamins, aspirin and medicine for diabetes, etc.

Why do side affect from chemotherapy occur?

Every patient responds to chemotherapy differently and which, if any, side affects they experience also differ from patient to patient. Side effects often depend on the specific drug or drugs used the dosage of the chemotherapy drug and the patient’s overall health. Side affect that occur are typically caused by chemotherapy affecting normal tissues that harbor rapidly dividing cells (which are the most sensitive to chemotherapy) such as the gastrointestinal tract and the bone marrow.

Some side affect are predictable but others not (such as an allergic reaction to a drug). Common side effects include fatigue, nausea, diarrhea, low blood counts, numbness or tingling of the hands/feet and hair loss. Please also review this websites section on chemotherapy side affect and reasons to immediately call you physician.

Again, because chemotherapy can injure healthy, usually rapidly dividing cells (such as blood cells, hair follicles, skin cells, gastrointestinal tract and reproductive cells in the ovary and testicle) while it attacks cancer cells, a wide array of side effects can develop in a patient. You may experience no side effects or just a few. The kind of side effects and how severe they are will depend on the type and dose of chemotherapy, how your body reacts, your age and general health. Some of the more common side effects are described below.

Fatigue

The fatigue is the most common side effect and can feel like chronic exhaustion or being “wiped out”. It can last days, weeks, or months. It can be cumulative and increase with time.  However, it usually goes away gradually as your body responds and recovers from treatment

Things you can do to help cope with fatigue include planning time to rest throughout the day; taking several short naps or breaks, rather than one long one; taking short walks or doing light exercise (with your doctor’s approval); eat well and avoid alcohol; continue to do what you enjoy doing, but listen to your body (if you feel tired, rest). On occasion stimulants may be suggested by your physician.

Nausea and Vomiting

Nausea and vomiting are common side effects of several chemotherapeutic agents. Chemotherapeutic drugs irritate the lining of the stomach and the small intestines as well as certain parts of the brain that control nausea. Although every patient is different, certain drugs are much more likely to cause nausea/vomiting than others such as cisplatin, carboplatinum, cyclophosphamide, procarbazine, adriamycin and dacarbazine.

Many things can influence the likelihood and severity of nausea and vomiting such as prior experience with motion sickness, previous bad experiences with nausea and vomiting, being young, having a history of heavy alcohol intake and being a women of menstrual age.

The following are helpful tips to control nausea and vomiting associated with chemotherapy:

  1. Drink liquids at least one hour before or after meals, instead of with your meal.
  2. Eat and drink slowly.
  3. Eat several small meals throughout the day, instead of one, two, or three larger meals.
  4. Breathe deeply and slowly when you feel nauseated.
  5. Avoid sweet, fried, greasy, or fatty foods.
  6. Rest, but do not lie flat for at least two hours after a meal.
  7. Try ginger tablets or ginger ale; ginger has been reported to reduce feelings of nausea.
  8. Wear loose-fitting clothes
  9. Practice relaxation techniques and seek complementary medicine intervention such as acupuncture.

Highly effective drugs have been developed to control chemotherapy associated nausea and vomiting. The most effective drug or combination of drugs as judged by your physician at OC Blood & Cancer Care will be prescribed to you:

These drugs include the following:

  • Lorazepam (Ativan)
  • Prochlorperazine (Compazine)
  • Metoclopramide ( Reglan)
  • Dexamethasone (Decadron)
  • Ondansetron (Zofran)
  • Granisetron (Kytril)
  • Aprepitant(Emend)

Neuropathy

Chemotherapy drugs can damage nerves, most often in the fingers and toes, which leads to burning, numbness, tingling, shooting pain, constipation or pain/cramping in the limbs. The most common drug offenders include paclitaxel, docetaxel, cisplatinum, vincristine and oxaliplatin. Predisposing conditions to chemotherapy induced neuropathy include preexisting neuropathy from any cause, diabetes, alcoholism or malnutrition.

Steps can be taken to relieve neuropathy if it develops so notify your physician at the earliest onset. There are many different medications and methods to help control the problem.

Hair Loss

Not all chemotherapeutic drugs cause hair loss so ask your physician. Hair loss usually occurs between 10 and 21 days after drug administration. It may happen suddenly and in large amounts or hair may fall out very gradually. The fall out can be a function of the rate of growth of your hair. It is a temporary problem and hair should grow back after treatment is stopped.

Things you can do to help care for your scalp and hair include using a mild shampoo and soft hair brush; practice gentle scalp care (low heat drying, avoid perming, dying or relaxing your hair, and use sunscreen/scalp protection.

Although not life-threatening, hair loss can be very distressing. Many people buy a wig or hairpiece, or use hats or scarves, to cover their head. If you buy a wig because of cancer treatment, it is a tax-deductible expense and may be covered in part by health insurance. The American Cancer Society office located on our campus has a very large wig bank and we urge to visit them.

Neutropenia, Anemia and Thrombocytopenia (Low Blood counts)

One of the most common side effects of chemotherapy is suppression of the bone marrow, the factory of blood cells (white cells, red cells and platelets), which results in neutropenia (low white blood cells), anemia (low red blood cells) and thrombocytopenia (low platelets).

Blood cell counts do not drop immediately after starting chemotherapy because the drugs do not kill cells already in the blood stream. Chemotherapeutic drugs, instead, prevent bone marrow from forming new blood cells. Each type of blood cell has an average life span, which has an impact on when each type of blood cell reaches its lowest levels, called the nadir.

Typically you will be required to obtain a complete blood count (CBC) before chemotherapy is administered to you to ensure it is safe for you to receive treatment. If your WBC/neutrophils, platelets or red cells are too low, treatment may be delayed, held or reduced. 

Neutropenia: Blood normally has between 4,000 and 10,000 WBCs per cubic millimeter (45-70% of these cells are neutrophils). The main function of white blood cells/neutrophils is to help prevent and fight infection. Because the white blood cells play such an important we monitor your white blood cell level very carefully. When your white blood cell count falls, it is known as neutropenia. If your WBC count falls, you will not automatically get an infection but you will be more susceptible to infection, which is a serious problem. Thus, it is important to watch for signs and symptoms of a possible infection such as fever, shaking chills, sore throat, confusion, shortness of breath, new cough, nasal congestion, burning sensation during urination, redness, swelling, and warmth at site of an injury or diarrhea.

Commercially available growth factors stimulate the production of different types of blood cells and help shorten the duration of neutropenia. The two growth factors that stimulate production of white blood cells in the body is granulocyte-macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF). Luekine is recombinant GM-CSF and Neupogen (filgastrim) is recombinant G-CSF. Both drugs are administered subcutaneously after chemotherapy on a daily basis until WBC recovery (schedule varies). Neulasta (peg-filgastrim) is a long acting form of neupogen and is only administered once subcutaenously the day after chemotherapy.

There are things you can do to decrease your risk of infection:

  1. Wash your hands often during the day (before you eat, after going to the bathroom, and after touching animals).
  2. Stay away from people who have illnesses that you can catch, like a cold, the flu, or chicken pox.
  3. Try to avoid crowds.
  4. Stay away from children who have recently received “live virus” vaccines, like chickenpox or oral polio.
  5. Maintain good mouth care.
  6. Do not eat raw fish, seafood, meat, or eggs.
  7. Clean cuts and scrapes right away and daily until healed.
  8. Report any signs of infection to your doctor immediately.

Anemia: Hemoglobin of less than 12 gm/dl for the context of this discussion defines anemia or low red blood cell (hemoglobin is another way to look at it). Red cells function to carry oxygen throughout the body. If anemia develops you may experience the following: fatigue, dizziness, feeling faint, shortness of breath, feeling a “pounding” heart or palpitations, chest pain or headache.

If such symptoms develop and are attributed to anemia you may be recommended a growth factor for red cells called erythropoietin (Procrit, Epogen); iron supplementation and/or red blood cell transfusion therapy

Thrombocytopenia: The normal range for the platelet count is between 150,000 and 450,000 per cubic millimeter. Platelets function to help stop bleeding and augment blood clotting. The risk of bleeding significantly increases when the platelet count falls below 50,000 and increases incrementally thereafter. The risk is also heightened if you are taking medications that poison platelets (aspirin, ibuprofen, Plavix, Effient, etc), supplements such as flaxseed oil which impair platelet function or medications that thin your blood (Coumadin, Lovenox,etc).

Signs that your platelet count may be low include the following: easy bruising, heavy or longer menstrual period, bleeding longer than usual after minor cuts or scrapes, bleeding gums or nose bleeds, developing large bruises and multiple small bruises (petechiae).

Treatment for thrombocytopenia varies and includes avoidance of trauma including intramuscular injections; holding, dose reducing or delaying chemotherapy and platelet transfusion therapy.

Lack of Appetite

Cancer itself as well as chemotherapy may cause a decreased or complete loss of appetite with resultant weight loss. The severity can range from mild to severe and may lead to malnutrition. The decrease in appetite is usually temporary and your appetite should return after chemotherapy has stopped, but it may take several weeks. Because chemotherapy can alter your sensation of taste, the therapy can affect the way some foods taste and smell to you, adding to your poor appetite and weight loss. Your taste and smell should also return to normal several weeks after chemotherapy has ended.

Weight loss and malnutrition should be avoided. Indeed, adequate nutrition is required by your body to fight the cancer and cope with chemotherapy and its side effects. Several prescribed appetite stimulants are available.

There are some things you can do to boost your nutritional status:

  1. Eat small, frequent meals throughout the course of the day.
  2. Avoid drinking fluids with meals to prevent from feeling full (again focus on high calorie/high protein foods).
  3. Eat foods high in protein, such as eggs, peanut butter, nuts, dairy products, tuna, and beans.
  4. Breakfast may be the most tolerable meal of the day; try to include at least one-third of your calories in this meal.
  5. Monitor and record your weight weekly; tell your doctor of any changes.

Mucositis, Head & Neck Cancer Supportive Treatment

Some chemotherapy drugs and radiation treatments can damage the lining of the mouth and throat down to the lower gastrointestinal tract. Such damage leads to inflammation, pain, ulceration and sores in the mouth, known as stomatitis, the throat, known as pharyngitis, the esophagus, known as esophagitis, the stomach, known as gastritis, and so forth.

Mucositis is a general term used to refer to inflammation and damage of any part or the entire gastrointestinal tract. Mucositis affecting the mouth and throat is very common with treatment for head and neck cancer and requires close attention and a dedicated multidisciplinary treatment team. It is caused by the damaging effects of chemotherapy and radiation which are typically given together for the aforementioned disease.

Symptoms and severity of mucositis vary and can include mouth and throat pain, difficulty swallowing, swollen gums, ulcerations, redness, sores, inability to eat (with resultant weight loss), increased mucus which is thick, nausea, fever, vomiting, pus or white plaques in the mouth, diarrhea and abdominal cramping. While mucositis is present the barriers or defense mechanisms against bacteria, fungus and yeast are breached and thus secondary infection may occur.

Factors that can increase the likelihood of developing mucositis, or that can increase the severity include poor oral or dental health, smoking or chewing tobacco, drinking alcohol, dehydration, diseases such as kidney disease, diabetes or HIV/AIDS, malnutrition, chronic irritation from ill-fitting prostheses or faulty restorations, concurrent oral viral or fungal infections.

Oral mucositis generally begins 5-10 days following the initiation of chemotherapy and lasts anywhere from one week to six weeks or more.  Resolution usually coincides with recovery of the white blood cell count if chemotherapy is the cause or with the completion of radiation therapy.

Preventative Measures:

  1. Complete dental evaluation and care; if you wear dentures, you will need to make sure they fit properly. If any work is needed (tooth extractions or refitting of dentures), it should be completed at least one month prior to starting therapy.
  2. Use mouth rinses regularly and daily (salt water rinses).
  3. Avoid alcohol and irritating foods, such as those that are spicy, hot, acidic or coarse.
  4. Use a soft bristle toothbrush and brush your teeth after eating 2 to 3 times each day. You should use a mild tasting toothpaste with fluoride, such as Biotene enzyme based products, as some flavorings and foaming agents such as SLS in toothpaste may irritate the mouth. You may augment these with Rx strength fluoride ones such as Prevident from Colgate.
  5. You should gently floss your teeth once daily.
  6. Rinse mouth (swish and spit) before and after meals and at bedtime with either salt water (1 tsp of table salt to 1 quart of water), or salt and soda (one-half teaspoon of salt and 2 tablespoons of sodium bicarbonate in 1 quart of warm water).
  7. If you smoke, it is extremely important that you stop.
  8. Avoid products that irritate the mouth and gums, such as strong flavored commercial mouthwashes and those with alcohol.
  9. Keep lips moist with moisturizers. Avoid using Vaseline (the oil base can promote infection).
  10. Increase your fluid intake.
  11. Try to include foods high in protein in your diet.
  12. If you wear dentures, remove them whenever possible to expose gums to air.  Loose fitting dentures can irritate the mouth and gums and should not be worn.  Do not wear dentures if mouth sores are severe.
  13. Sucking on ice chips during chemotherapy administration, has shown some effect in preventing mucositis caused by 5-FU (fluorouracil).
  14. Your physician will consider the use of Gelclair and Zilactin, which are mucosal protectants that work by coating the mucosa and forming a protective barrier.
  15. Specifically, in the case of head and neck cancer your physician will consider Amifostine (Ethyol), a drug that offers some protection against the damage to the mucosa caused by radiation. Other agents that have been studied in this population of patients include: capsaicin (derived from chili peppers), glutamine, prostaglandin E2, Vitamin E, sucralfate, and allopurinol mouthwash with varying degrees of success.
  16. Use antacid such as ranitidine or omeprazole.
  17. In the case of patients undergoing marrow/stem cell transplantation, the use of palifermin, a recombinant keratinocyte growth factor, should be considered.

Treating Mucositis:

  1. Increase brushing (with the softest tooth brush possible) to every 4 hours and at bedtime. It is important to brush and floss very gently.
  2. Rinse your mouth frequently with antiseptic mouth rinses, such as Peridex or Periogard. You can also make your own rinse by mixing 1 teaspoon of baking soda in 8 ounces of water or ½ teaspoon salt and 2 tablespoons of sodium bicarbonate dissolved in 4 cups of water. This solution can also reduce some of the severe phlegm / mucous production that is a by-product of the treatments.
  3. Saliva production will decrease on therapy for head and neck cancer which will cause xerostomia (dry mouth). Chewing ice chips, chewing sugarless gum, or sucking tart sugar free candy to increase moisture. Artificial saliva products can also be used.
  4. Over-the-counter products are available such as enzyme based Oral Balance, Biotene toothpaste and mouthwash that are free of the strong flavors and foaming agents that can be very irritating to sensitive tissues under treatment. Since your saliva barrier is compromised, you should avoid eating or drinking products containing sugar to prevent cavities.
  5. To help clean oral sores you can rinse with a solution consisting of 1 part of 3% hydrogen peroxide with 2 parts of saltwater (1 teaspoon of salt dissolved in 4 cups of water).  For mild fungal infections, topical oral suspensions or dissolving tablets can be prescribed that contain anti-fungals. You will need to swish or dissolve the medicine in your mouth and, depending on your doctor’s directions, either swallow or spit out the medicine. Also, if you wear any dental appliances, you should soak them in antiseptic solutions.
  6. In mild cases of pain, ice pops, water ice, or ice chips may help numb the area. If more local pain control is required Topical pain relievers include lidocaine, benzocaine, dyclonine hydrochloride (HCl), and Ulcerease® (0.6% Phenol).
  7. Corticosteroids such as prednisone may be effective also in pain relief.
  8. Benadry elixir, lozenges and analgesics may help reduce mouth pain.
  9. Swishing and gargling the anesthetic gel viscous Xylocaine 2% can help you eat if you have pain in your mouth, pharynx or esophagus. Use 1 tsp.(5 mL) viscous Xylocaine before meals. (Hold in mouth for one minute, then spit out.) This may increase your ability to eat by mouth while the anesthetic effects are working.
  10. Cepacol Lozenges, Chloraseptic spray and lozenges, or the use of tea (particularly chamomile) for swishing and gargling may be of some help.
  11. Biotene mouthwashes, which combine enzyme based protection and soothing mouth moisturizers are available over the counter.
  12. Swish diluted milk of magnesia, Carafate slurry or Mylanta around your mouth. Orabase B is an over-the-counter agent that is an adhesive paste with a topical anesthetic (benzocaine) that may be helpful.
  13. You can also use topical products like Orajel or some prescription products like viscous lidocaine to eliviate discomfort temporarily.
  14. A common topical agent is a so-called “magic mouthwash”.  Some patients report good results with a combination of Lidocaine (a numbing agent), Benadryl, Maalox, and Nystatin (an antifungal).
  15. Advil, Tylenol and narcotic pain killers are often required to ease pain/discomfort. Indeed adequate pain relief is essential as the lining of the mouth and gastrointestinal tract heal.

Reproduction and Sexual Problems

Chemotherapy can cause reproductive and sexual problems. Whether or not you experience these changes will depend on factors such as your age, which chemotherapy drug you are exposed to as well as the dose and duration of treatment. Again, each patient may experience different side effects or none at all.

An important issue is fertility preservation in young patients cured of their cancer. Your physician at OC Blood & Cancer Care can counsel you about this potential problem as well as available options to maintain fertility.

Some reproductive and sexual changes a woman may experience during or after chemotherapy include the following:

  1. Temporary or permanent damage to the ovaries
  2. Disruption or stoppage of the menstrual cycle
  3. Symptoms of early menopause, such as hot flashes, vaginal dryness, and tightness during intercourse
  4. Irritation and dryness of the lining of the vagina
  5. Vaginal infections
  6. Some reproductive and sexual changes a man may experience during or after therapy include the following:
  7. Decrease in sexual desire
  8. Difficulty getting and maintaining an erection
  9. Damage to sperm
  10. Permanent sterility
  1. A fever (greater than 100.4) has developed or you have chills or others signs of an infection.
  2. You feel light-headed, dizzy when standing or rising from a sitting position.
  3. Diarrhea has not abated over 24-48 hours despite treatment.
  4. Bleeding has developed from your nose, gums or red spots on your arms or legs are apparent.
  5. Nausea and/or vomiting is not controlled and/or impairs maintenance of
  6. Sores have developed on your mouth and/or throat.
  7. White patches have developed in the mouth.
  8. Bloody or black stools have been noted.
  9. A cough, trouble breathing, or chest pain has developed.
  10. Calf pain, swelling, or redness in the legs or feet (which could signify a blood clot) have developed.
  11. Abnormal vaginal discharge, itching, or odor has developed.
  12. New or uncontrollable pain has developed.
  13. Numbness, tingling, or pain in your extremities has developed.
  14. Redness, swelling, increasing pain, excessive bleeding, or a “pimple” at the site of your IV or chemotherapy administration.
  15. Hearing or vision changes, gait impairment (falls or near falls), new unexplained headache, speech impairment, excessive sleepiness or weakness of an extremity had have developed.
  16. Exposure to someone with an infectious illness, including chickenpox.
  17. Unexplained weight gain or loss of 10 pounds or more.
  18. An unexplained rash has developed.

In case of an emergency, call 911.

Phone Calls, After-hours and Emergencies

If you need urgent care during office hours, call the office immediately (714-378-7330) and tell the person answering the call that it is an emergency. A nurse, physician assistant or doctor will evaluate your situation and give your or caregiver immediate instructions.

Calls about medication refills, appointments, or other routine concerns should be placed during office hours, 9 a.m. to 5:00 p.m. Monday through Friday. Narcotic prescriptions cannot be filled after office hours. Our goal is to return calls within one business day.

After hours patient and hospital calls (from 5 PM-9AM weekdays and on weekends, holidays) are processed through our answering service. A physician or physician assistant is always available and will usually immediately take the call. If the on-call provider is temporarily occupied, a call/message will be returned with minutes. If you do not receive a call back within 30 minutes please call the answering service again.

IF AT ANY TIME YOU EXPERIENCE A LIFE-THREATENING EMERGENCY, CALL 911 IMMEDIATELY. INFORM THE ER ON ARRIVAL THAT YOU ARE UNDER OUR CARE.