A Patient’s Guide to Chemotherapy

1. A Patient’s Guide to Chemotherapy Zeina Nahleh, MD, F.A.C.P. Associate Professor of Medicine And Biomedical Sciences Chief, Division of Hematology-Oncology Department of Internal Medicine TTUHSC - Paul L. Foster School of Medicine 4800 Alberta Ave El Paso, TX 79905 (915) 545-6618 (office) (915) 545-6634 (fax)

2. Dietary Suggestions…For eating well on the day of the treatment and the day after… Eating before treatment We suggest that you eat before receiving chemotherapy. If you have a late morning afternoon appointment, eat a snack before your appointment. Otherwise, eat a regular breakfast or lunch. No fried or greasy foods.

3. Prevention of Nausea • After receiving treatment we have found our patients have less nausea if they are not hungry. • You may need a mid morning and mid afternoon snack to prevent nausea. • You should eat a bedtime snack for 2-3 days after chemotherapy. • The best snacks are starchy and bland such as pretzels, crackers, toast, English muffins, bagels, vanilla wafers, animal crackers or popcorn that is no greasy.

4. Eating if you are nauseated • The above starchy, bland foods would also be good choices if you are nauseated. • Eat small amounts with sips of clear liquids and increase amounts slowly.

5. Morning after chemotherapy For 2-3 days after chemotherapy you should take your medications with food unless specifically told to take on an empty stomach. Drink your fluids with breakfast, not before.

6. Foods to avoid the day of treatment and the day after treatment • Fatty, greasy or fried food • Red meats-tend to have a bitter taste • Spicy foods-hard to digest • Foods with strong odors especially if you are cooking.

7. Toast and crackers Skinned chicken (baked or broiled) English muffins Baked fish Animal crackers Fruits and vegetables that are soft or bland, such as canned peaches Yogurt Sherbet Pretzels Beverages sipped slowly between meals Angel food cake Pound cake Macaroni and cheese Oatmeal Cereal Waffles Pancakes These foods are generally easy to digest, but are only a short list possibilities.

8. Some Clear Fluid Suggestions • Water • Grape juice • Apple juice • Cranberry juice (or combinations) • Kool-Aid • Soft drinks • Tea • Chicken soups or broth • Crushed ice • Ice popsicles • Jell-O • Gatorade

9. General Guidelines Medications to avoid • Avoid taking too much aspirin and ibuprofen (such as Motrin, Advil) because the medications effect your platelets as does chemotherapy. Platelets are cells in your blood involved in your blood clotting.

10. Mouth care Guidelines Mouth care is very important while you are getting treatment. Sensitive tissues in your mouth may become irritated during treatment. • Use a soft toothbrush only • Any commercial toothpaste is fine • Any commercial denture cleanser is fine • Do not use any commercial mouth wash • Ask your doctor for a special mouthwash • Keep your lips moist with something like lipstick, Chapstick, Vaseline or Blistex.

11. If you develop mouth soreness • For mouth soreness swish and gargle with baking soda mouth wash (mix ½ cup warm water with1/2 teaspoon baking soda) after meals and at bedtime. • If your mouth soreness increases, call your physician for additional instructions, especially if the soreness interferes with eating or drinking.

12. For diarrhea lasting longer than 12 hours Try Kaopectate or Imodium AD (loperamide) tablets. Please call if the diarrhea continues after another 24 hours, especially if associated with abdominal pain or cramps.

13. If you experience any of the followingproblems call the office within 24hours • Signs and symptoms of infection including fever greater than 100.5F, shaking chills, burning on urination or cough productive of dark mucus. Please have a thermometer available that you can read. • Vomiting that doesn’t stop with the medicine we have ordered for nausea. • Your platelets may be low if you notice any unexplained bruising or bleeding. • Severe sudden headache, change in balance, or sudden change in vision. • Any unusual physical symptoms that began after chemotherapy.

14. To refill your prescription of a medicine ordered by our office • Check on the medications you need and ask for refills during your visit with the doctor. • If refills are needed between visits, please call 24 hours in advance. You can pick up written prescriptions the next day or they can be mailed to you.

15. Nutrition You should consult with your physician or the dietitian at any hospital if you are using alternative therapies including high does of vitamins or minerals, herbal preparations or changing your diet. They will evaluate the safety of these therapies with your chemotherapy.

16. Reminder • You may bring food and something to drink with you to have during your treatment

17. Clinical Trials Zeina Nahleh, MD, F.A.C.P. Associate Professor of Medicine And Biomedical Sciences Chief, Division of Hematology-Oncology Department of Internal Medicine TTUHSC - Paul L. Foster School of Medicine 4800 Alberta Ave El Paso, TX 79905 (915) 545-6618 (office) (915) 545-6634 (fax) zeina.nahleh@ttuhsc.edu Are you interested in taking part in a clinical trial?

18. Would you like more information about clinical trials? What is a clinical trial? Clinical trials are research studies that involve patient volunteers to help find different ways to treat diseases such as cancer. Each study is designed to answer specific scientific questions and help find potentially better ways to prevent, diagnose, or treat cancer. What happens during a clinical Trial? When someone chooses to take part in a clinical trial, the care they receive is much like the care they would otherwise receive. However, there is often additional monitoring for the purpose of learning about potential side effects and benefits of the clinical trial. Some trials simply test a study regimen, and all participants receive this same regimen. Other trials may compare a study regimen to the standard treatment. In this type of study, participants are randomly assigned to receive one or the other. Neither the participant nor their doctor can choose which one they will receive for important scientific reasons. Some people worry that they will not know which drug they are receiving or that they will receive a placebo, sometimes called a “sugar pill”. Placebos are never used in place of a treatment that is known to work. Participants will always be told before agreeing to take part if a placebo is going to be considered. Why are clinical trials important? Clinical trials are a vital part of the process in finding new cancer treatments. These research studies are conducted to determine if a study drug is safe and effective. Today’s research will guide the improvements for tomorrow’s cancer care. What is “informed consent”? Informed consent means that patients must be told the key facts about a clinical trial before deciding whether to take part. If the patient agrees to take part, the informed consent process involves signing a form that details the entire clinical trial, possible side effects, and potential risks and benefits. Participants may withdraw their decision to participate at any time for any reason. Should I participate in a clinical trial? The decision to take part in a clinical trial is a personal one. You may wish to talk to your family and loved ones, as well as members of your health care team, before deciding. As with all current standard treatments, there can be possible risks as well as benefits form taking part in clinical trials. Study drugs may be found to be more or less effective than current standard treatments and have side effects not yet known. You will be informed of these risks as much as possible. Your health care team will give you the information you need to make the decision that is right for you. Where can I get more informations regarding clinical trials? For More Information, visit the National Cancer Institute's education page about cancer clinical trials at: http://www.cancer.gov/clinicaltrials/

19. MANAGING FATIGUEduring treatment Since fatigue is the most common symptom in people receiving chemotherapy, patients should learn ways to manage the fatigue. Patients should be informed about the following: • Possible medical causes (anemia, not enough fluids, breathing problems etc..) • To observe their rest and activity routines • To identify environmental or activity changes that may help decrease fatigue • The importance of eating enough food and drinking enough fluids • To schedule important daily activities during times of less fatigue, and cancel unimportant activities that cause stress • To avoid or change a situation that causes stress • To engage in attention-restoring activities • To observe whether treatments being used to help fatigue are working Zeina Nahleh, MD, F.A.C.P. Associate Professor of Medicine And Biomedical Sciences Chief, Division of Hematology-Oncology Department of Internal Medicine TTUHSC-PLFSOM

20. Managing Fatigue During Treatment Managing fatigue during treatment Fatigue is the most common complaint of people with cancer, especially those receiving treatment for their cancer. • People with cancer may express it in different ways, such as saying they feel tired, weak, exhausted, weary, worn-out, fatigued, heavy, or slow. • Fatigue may affect how the person feels about him-or herself, his or her daily activities and relationships with others, and whether he or she continues with cancer treatment. • Patients receiving some cancer treatments may miss work, withdraw from friends, need more sleep, and, in some cases, may not be able to perform any physical activities because of fatigue. • Fatigue is complex , and has biological, psychological, and behavioral causes Patients should tell their doctors when they are experiencing fatigue and ask for information about fatigue related to underlying causes and treatment side effects.

21. Causes of Cancer Fatigue • The causes of fatigue in people • with cancer are not always known. • Fatigue can occur for many reasons. • The extreme stress that people with cancer experience may be all that is needed to trigger Fatigue. • However, there may be other reasons. Patients should be educated that Fatigue is a common side effects of cancer treatment: cancer treatment like radiation therapy or chemotherapy commonly causes fatigue due to collection of toxic substances produced by cells or the increased energy needed to repair damaged skin tissue . Medications to treat pain, depression, vomiting and other conditions are also common causes of fatigue in patients with cancer.

22. Treatment of Cancer Fatigue • To determine the cause and best treatment for fatigue, the person’s fatigue pattern must be determined, and • all of the factors causing the fatigue must be identified. • The following factors must be evaluated : • Fatigue pattern, including how and when it started, how long it has lasted, and its severity, plus any factors that make fatigue worse or better. • Type and degree of disease and of treatment-related symptoms and/or side effects. • Treatment history. • Current medications. • Sleep and/or rest patterns and relaxation habits. • Eating habits and appetite or weight changes. • Effect of fatigue on activities of daily living and lifestyle. • Psychological profile, including an evaluation for depression. • Complete physical examination • Other factors (for example, anemia, breathing problems, decreased muscle strength).

23. Treating The Common Causes of Cancer Fatigue • Sleep disorder and inactivity • Disrupted sleep, poor sleep habits, less sleep at night, sleeping a lot during the day, or no activity during the day may contribute to cancer-related fatigue. Patients who are less active during the daytime and awaken frequently during the night report higher levels of cancer-related fatigue. Sleep disorder and insomnia should be addressed and may require medications. • Exercise , including light walking helps many people with cancer, leading to more energy, better appetite, and improved quality of life • Nutrition factors Fatigue often occurs when the body needs more energy than the amount being supplied from the patient’s diet. In people with cancer, 3 major factors may be involved: a change in the body’s ability to process food normally, an increased need by the body for energy (due to tumor growth, infection, fever, or problems with breathing), and a decrease in the amount of food eaten (due to lack of appetite, nausea, vomiting, diarrhea, or bowel obstruction). Special attention to nutrition is necessary. Diet supplementation with iron, vitamins and proteins may be needed • Anemia Anemia may be a major factor in cancer-related fatigue and quality of life in people with cancer. Anemia may be caused by the cancer, cancer treatment, or may be related to other medical causes.

24. Activity and Rest People with cancer should set priorities and keep a reasonable schedule. Any changes in daily routine require the body to use more energy. An activity and rest program should be discussed with the health professionals to make the most of a patient’s energy. Practicing sleep habits such as not lying down at times other than for sleep, taking short naps no longer than one hour, and limiting distracting noise during sleep may improve sleep and allow more activity during the day. • Addressing the Psychological Factors: Anxiety and depression are the most common psychological disorders that cause fatigue. Depression may be a disabling illness that affects approximately 15% to 25% of people who have cancer. Patients experiencing depression may have loss of interest, difficulty concentrating, mental and physical tiredness, and feelings of hopelessness. The fatigue from physical causes can become worse and last longer than usual, even after the physical causes are gone. Antidepressants might be needed. • Decreased attention span and difficulty understanding and thinking are often associated with fatigue. Attention problems are common during and after cancer treatment. Attention may be restored by activities that encourage relaxation like gardening, meditation, prayers. In addition, sleep is also necessary.