Cancer is a term for the abnormal growth of cells. Our bodies contain a wide array of cells and each cell contains twenty-three pairs of chromosomes. A cancer cell contains an abnormal chromosome caused by damage or a genetic change. These damaged cells grow rapidly and begin to multiply until it forms a lump (or tumor). Tumors can be either malignant or benign. Benign tumors can be left alone because they do not invade other cells. Malignant tumors can spread to other sites and start other growth. This spreading of cancer is called metastasis. Usually, tumors will grow at a primary site. It is the cancer cells that shed off the primary tumor into the bloodstream and spread to other parts of the body.

The most common types of treatment are surgery, radiation, chemotherapy, hormone therapy, and biotherapy/targeted therapies. These methods can be used alone or in combination with each other. Surgery and radiation are considered local treatments and are used primarily to treat cancers that are in one spot. Chemotherapy, hormonal therapy, biotherapy, and targeted therapies are all considered systemic treatments in that they travel through the bloodstream, reaching and affecting cells throughout the body.  

The goals of systemic therapy such as chemotherapy include one of the following: 

• Cure: when chemotherapy destroys cancer cells to the point that they can no longer be detected in your body and do not grow back
• Control: when chemotherapy keeps cancer from spreading, slows its growth, or destroys cancer cells that have spread to other parts of the body
• Palliation: to ease cancer symptoms with chemotherapy to shrink tumors that are causing pain or pressure.
   

Hormones are natural substances made by glands in the body. The hormones are carried in the bloodstream and act as messengers between one part of the body and another. They have many effects and one of these is controlling the growth and activity of certain cells and organs.

The goal of hormone therapy with cancer is to use medications to block the effect of hormones in people with cancers that are hormone-sensitive or hormone-dependent.

Biotherapy or biological therapy is a treatment used to boost or restore the ability of the immune system to fight cancer, infections, and other diseases. This type of treatment uses substances made from living organisms to treat disease. These substances may occur naturally in the body or may be made in the laboratory. In cancer, some biotherapies stimulate or suppress the immune system to help the body fight cancer. Other biotherapies attack specific cancer cells, which may help keep them from growing or even kill them. Biotherapy may lessen certain side effects caused by cancer treatments.

Biosimilar are medicines that have been made to be highly similar to an existing approved biologic medicine (also called a “reference product”) and are used for cancer treatments. Biosimilars may offer a less costly alternative to existing reference biologic medicines while providing the same effectiveness and safety as with the referenced biotherapy product.

Immunotherapy is a treatment that uses certain parts of a person’s immune system to help the body fight infections and diseases such as cancer. It can be done by stimulating your own immune system to work harder or smarter to attack cancer cells. It can also be done by giving you immune system components, such as man-made immune system proteins.

Immune checkpoint inhibitors (a type of immunotherapy) offer a promising new way to treat cancer for some patients. But these medicines can occasionally cause your immune system to attack normal organs and tissues in your body, affecting the way they work. Serious side effects typically occur in less than 5 percent of patients, but certain mild side effects can occur in up to 30-50 percent of patients.

Contact your health care professional right away if you think you may be experiencing...

• Brain Inflammation - Fever; confusion; changes in mood or behavior; neck stiffness; seizures; extreme sensitivity to light.
• Eye Problems - Blurry or double vision or other vision problems; eye pain or redness.
• Hormone Gland Problems (Especially the Thyroid, Pituitary, Adrenal Glands, and Pancreas) - Persistent or unusual headaches; extreme tiredness; weight loss or gain; rapid heartbeat; increased sweating; hair loss; constipation; dizziness or fainting.
• Heart Problems - Inflammation of the heart muscle; an irregular heartbeat.
• Liver Problems - Yellowing of the skin or the whites of the eyes; severe nausea or vomiting; pain on the right side of the stomach area; dark urine; bleeding or bruising more easily than normal.
• Lung Problems - New or worsening cough; shortness of breath.
• Kidney Problems - Decrease in the amount of urine; blood in the urine.
• Intestinal Problems - Diarrhea or more bowel movements than usual; stools that have blood or are dark, tarry, or sticky; severe stomach-area pain.
• Skin Problems - Rashes; itching; blistering; painful sores or ulcers.
• Joint or Muscle Problems - Severe or persistent muscle or joint pain; severe muscle weakness.
• Nerve Problems - Numbness or tingling in hands or feet; unusual weakness in legs, arms, or face.

Source: National Comprehensive Cancer Network

Targeted cancer therapies use drugs or other substances that block the growth and spread of cancer by interfering with certain molecules (molecular targets) that are involved in the growth, progression, and spread of cancer.

Targeted therapies differ from standard chemotherapy in several ways: 

• Target therapies act on specific molecular targets whereas standard chemotherapy acts on all rapidly growing and dividing normal and cancerous cells
• Targeted therapies are deliberately chosen or designed to interact with their target, whereas standard chemotherapies were identified because they kill cells
• Targeted therapies are often cytostatic (they block tumor cell proliferation), whereas standard chemotherapy agents are cytotoxic (they kill tumor cells).
   

We often treat disease using drugs. Much like we take aspirin for a headache we use chemotherapy drugs to fight cancer. Cancer cells are not serving any function. They are not as strong and healthy as a normal cell. Chemotherapy is systemic, meaning it travels through the entire body and enters the cells that are rapidly growing and dividing. There are many places in our body that contain fast-dividing cells:

1.  Hair Cells: grow very rapidly. We always have new hair growing. This is also the reason some patients will lose their hair.
2.  Mouth, Throat, and Gastrointestinal Tract (swallowing tube and bowels): The lining of the mouth replaces itself every few days and may be damaged by chemotherapy.
3.  Reproductive System: (Men) Chemotherapy may lower the number or function of sperm cells. These changes can result in infertility which could be temporary or permanent. Infertility may affect a man’s ability to father a child but does not affect his ability to have sexual intercourse. It is recommended that men use an effective means of birth control throughout their treatment. 
4.  Reproductive System: (Women) Chemotherapy can damage the ovaries and decrease the production of hormones like estrogen. This can cause irregular menstrual periods or even stop menstruation. The hormone effects of chemotherapy may cause symptoms like hot flashes, burning, dryness, or itching of vaginal tissues, like menopause. This may result in uncomfortable intercourse or vaginal infections. Damage to the ovaries may cause infertility or the inability to become pregnant. This could be temporary or permanent. Pregnancy is possible during chemotherapy but is not advised as these drugs can cause birth defects. It is recommended that women of childbearing age use birth control throughout their treatment.
5.  Bone Marrow: A spongy tissue that plays a major role in the development of blood cells. The two types of bone marrow are “red marrow”, which consists mainly of hematopoietic tissue, and “yellow marrow”, which is mainly made up of fat cells. Red blood cells, platelets, and most white blood cells arise in red marrow: 

• White blood cells function as infection-fighting cells
• Red blood cells carry oxygen to the body’s tissues
• Platelets are blood-clotting cells.  

These cells may be affected by the type of chemotherapy or regimen ordered. Typically blood counts will decrease in 7-14 days after treatment and will improve prior to the next treatment cycle.

• There is really nothing a patient can eat, can do or not do to prevent this from happening. 
• Your oncologist will follow your blood counts closely and adjust your chemotherapy dose as needed.

Chemotherapy may be used: 

• As a primary treatment to destroy cancer cells before another treatment to shrink a tumor
• As an adjuvant treatment after another treatment (surgery, radiation, etc.) to destroy any remaining cancer cells, and to relieve symptoms of advanced cancer. 

It is important to remember that it is impossible to attack the cancer cells without influencing normal cells, but most of these side effects are tolerable, treatable, and preventable.

Chemotherapy treatments may be given in many ways:

• Intravenous (IV): Through a tube in the vein, typically placed in the arm. Your doctor may recommend having a vascular access device (VAD) placed. The two most common VADs used at NHO are PICCs (Peripherally inserted central catheter) and implantable ports. PICCs are inserted in a vein in the arm and threaded into a large vein above the right side of the heart called the superior vena cava. Implantable ports are placed under the skin in the chest and the other end of the port is threaded into the superior vena cava. This can then be accessed with a special needle if needed. Both devices stay in longer than an IV catheter placed in your vein in the arm. 
  • Continuous Home Infusion Chemotherapy: Chemotherapy given slowly over one or more days is called continuous infusion chemotherapy. This type of treatment is given with an infusion device that is attached to your VAD (PICC or port). The device will ensure that the chemotherapy is given at the proper speed and that the right amount is received. Typically, a nurse will verify and connect you to the continuous infusion treatment in the infusion area. Most patients carry their device, hidden in a pouch, wherever they go while the chemotherapy is infusing.  
• Orally: Taken by mouth in the form of pills, capsules, or liquid that you swallow.
• Intracavitary: Given directly into a body area.
• Intra-arterial: Given directly into an artery.
• Topically: Placed on the skin where it is absorbed.
• Intrathecally: Given directly into the cerebrospinal fluid (CSF).

We have oncology-trained nurses to administer your chemotherapy. Some chemotherapy is administered intravenously (IV-via vein). Our nursing staff is very skilled at starting IVs. If they are not comfortable with the vein function, they will restart your IV.  We know this is an inconvenience, but we do not want to compromise your safety. If the chemotherapy agent would seep out of the vein, it could cause tissue damage. For this reason, it is very important that you notify the healthcare team immediately if you should experience burning or pain at the injection site. You are a partner in the treatment process. If the health care team determines they have difficulty starting your IV, they may discuss with you the benefits of having a vascular access device (VAD) place.
 

Your healthcare provider has ordered chemotherapy for you to take by mouth (orally). Chemotherapy pills are convenient but can be hazardous to others or to the environment. Please follow the following instructions and safety precautions before, during, and after your chemotherapy treatment.

The process from the physician order through to receiving the drug:

• The physician orders the oral chemotherapy treatment: NHO team members will work with your insurance company to ensure that the medication will be approved before you begin taking the medication.
• You may receive a phone call from the pharmacy regarding co-pay information. Remember that if the co-pay amount is more than you can afford, you need to state to the pharmacy: “I am unable to afford this”. By stating this, the pharmacy will be able to help you with obtaining financial assistance. The pharmacy is not able to offer the assistance unless you state that you cannot afford the co-pay. If the pharmacy is unable to obtain financial assistance for you, please call NHO at 402-484-4900 to explore other options.
• If the pharmacy calls you regarding the delivery of the medication, call NHO at 402-484-4900 to inform us.
• Do not start the medication until you have contacted us and received instructions from us on how to take the medication.
• Once the insurance approval is obtained, you will be scheduled to come in for an appointment to meet with the nurse to discuss detailed information regarding the medication your physician prescribed for you.
• This process typically takes 1-3 weeks to complete from when the order is received to when the patient receives medication.

Storing, handling, and disposing of Oral Chemotherapy: 
(See also specific drug information sheet)

• Keep your chemotherapy medication in a safe place, out of reach of children and pets.
• Avoid storing your chemotherapy pills in the bathroom due to high moisture, or areas that are very hot or very cold.  
• Check medication labels to see if your chemotherapy needs to be refrigerated or protected from light.
  • If refrigeration is necessary, you will need to use a separate, leak-proof container and store the medication in an area where it does not come into contact with food.  
  • Do not store chemotherapy in the freezer.
• Wash your hands well with soap and water before and after handling chemotherapy or the containers that they come in.
• Pregnant women should not handle chemotherapy pills or body waste from people who are receiving chemotherapy.
• If a caregiver is preparing the medication for the patient, they should wear gloves to avoid touching the medication with their bare hands. They should wash their hands with soap and water after removing gloves. These gloves are for one-time use. 
• If the patient is self-administering the medication, they do not need to wear gloves. They should wash their hands with soap and water after handling the chemotherapy.
• Keep your oral chemotherapy apart from your other medications.
• In general, oral chemotherapy drugs should not be chewed, crushed, cut, or dissolved.
• If the chemotherapy drug is discontinued and you have drug remaining, talk with your healthcare team about how to dispose of the unused drug.  
  • Generally speaking, if you have unused oral chemotherapy pills, please return them to the pharmacy where the prescription was filled. 
  • Do not flush down the toilet, dump in the sink, or throw away in the trash.  
  • It is important to properly dispose of expired or medication you are no longer taking.  
  • For up-to-date information on how to dispose of medication, please visit one of the following websites:  
    • FDA or Dispose My Meds
      • https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm
      • http://disposemymeds.org/

Possible drug/drug and drug/food interactions:

• Oral chemotherapy can be affected by prescription and over-the-counter medications, as well as supplements and food. Your healthcare team will review your medication and allergy history before initiating the therapy and they will review the potential drug/drug and/or drug/food interactions specific to the chemotherapy drug you are taking.
• Foods can also affect the absorption rates of chemotherapy. Your healthcare team will discuss with you if you should take with food or on an empty stomach.

Plan for missed doses:

• Your healthcare team will discuss with you what to do if you miss a dose of the chemotherapy drug.
• It is very important to keep track of any missed doses and report them to your healthcare team.
• In general, for oral chemotherapy taken once or twice a day, the missed dose can be taken if it is within six hours of the normal dosing time. If it is more than six hours, then the medication should be skipped.

Side-effect management:

• Oral chemotherapy agents have side-effects unique to each drug category. Your healthcare team will discuss what possible side-effects may occur, specific to the drug you are taking as well as how to best manage the side-effects and what should be reported to the healthcare team.

Refill Process:

• Most oral chemotherapy is now dispensed by specialty pharmacies and mailed directly to the patient’s home or to the physician’s office. It is important that patients using specialty pharmacies plan ahead and order the refills early enough to ensure that the refill is received before they run out of their medication.

Blood Monitoring and Follow-up:

• Blood monitoring will be done throughout the treatment, your healthcare team will discuss the specific monitoring needed for the chemotherapy agent(s) being taken.
• Follow-visits with the healthcare provider are very important to monitor the effectiveness and possible side-effects. Your healthcare team will provide you with a follow-up appointment schedule, specific to the needs of the drug you are taking.
• Follow-up between office visits may occur via a phone call by a member of the healthcare team, calling to evaluate adherence and toxicity as well as reinforce the treatment plan and how to manage side-effects if they occur.
   

The drugs used to treat cancer may be termed hazardous. Hazardous drugs and their metabolites may remain active in urine and stool at the time of administration, and beyond the treatment day. Typically, hazardous drugs are eliminated within 48 hours after administration. The metabolites are broken down by the kidneys, liver and are eliminated through body fluids (urine, stool, sweat, gastric, semen, vaginal, etc.).

There are a variety of factors that influence how long it takes for the drugs to leave your body, including the type of chemotherapy that you received, the presence of other medications in your system, your age, and how well your kidneys and liver function. Damage to an organ can slow down the process of drug elimination.  

There are certain precautions that should be taken for the first 48 hours after receiving chemotherapy.

• Handling body fluids: It is important to handle body fluids safely while on chemotherapy and for 48 hours following the final dose.  
  • Always wash your hands well with soap and water after handling body fluids or using the bathroom.  
  • When using the toilet, close the lid and flush the toilet.  
  • If unable to control your bowel or bladder, use a disposable plastic-backed pad to soak up the urine or stool.  
  • Wear gloves and place the soiled pad into a sealed plastic bag for disposal.  
  • Remove gloves and wash hands with soap and water.
• Sexual activity: Most patients can continue sexual activity during chemotherapy, but some special precautions may be necessary:
  • Traces of chemotherapy may be present in vaginal fluid or semen for up to 48 hours after each dose of chemotherapy.  
  • Barrier protection is recommended (i.e. condoms).
  • Avoid oral sex for the 48-hour post-treatment period.  
  • Kissing, hugging, and touching are acceptable.  
• Childbearing during treatment:
  • Should be avoided during chemotherapy. 
  • Men & Women of child-bearing age should use birth control.
  • Birth control measures should be discussed with your physician before beginning chemotherapy. 
  • Birth control measures should be maintained throughout chemotherapy and for several months after chemotherapy is completed.  
  • Talk with your physician before attempting to conceive/father a child.
     

The cerebrospinal space is the area surrounding the spine and brain, which contains cerebrospinal fluid (CSF). CSF is a colorless fluid, produced in the ventricles of the brain, which acts as a buffer around the brain and spinal cord and functions to keep them safe from injury.

Intrathecal (IT) chemotherapy is used to treat cancers that have entered into the CSF. When cancer enters into the CSF, it may be called CNS (central nervous system) involvement. Chemotherapy given by other routes, such as intravenously (IV) or by mouth (PO), does not typically cross into the CSF, and therefore, is unable to treat these cancer cells. Giving chemotherapy directly into the CSF allows the medication to reach the cancer cells and decreases the potential systemic (overall) side-effects that IV or PO chemotherapy can cause.

Intrathecal chemotherapy may be used to treat or prevent cancer in the CSF. IT chemotherapy may not have been part of your original chemotherapy plan but added because cancer cells are found in your CSF.

Intrathecal chemotherapy is administered either via: 

• A lumbar puncture is a sterile procedure in which a needle is placed into the cerebrospinal space in between two vertebrae in your spine (lower back). 
  • The needle may be used to remove CSF and/or to administer the chemotherapy through a syringe, attached to a needle, directly into your CSF.  
• An Ommaya reservoir is a small port that is placed, by a surgeon, underneath the skin on the head, which is attached to a tube that is threaded into a ventricle (open space) in the brain. 
  • An Ommaya reservoir may then be accessed during a sterile procedure, by placing a needle through the skin into the port, whereby CSF may be removed and/or chemotherapy administered.  
• After the procedure is completed, either through a lumbar puncture or Ommaya, the needle will be removed, and you will be instructed to lie flat for 30-60 minutes. This will help the chemotherapy travel throughout your CSF and kill the cancer cells and may help prevent a headache.

If CSF was removed, either through a lumbar puncture or from your Ommaya shunt, your body will have to produce more CSF to refill the space. When you have less CSF circulating than what is normal, you can develop a headache (lying flat may prevent this symptom). If you experience any of the following side-effects, notify your healthcare provider immediately: headache, dizziness, uncontrolled bleeding from the needle insertion site, blurry vision, uncontrolled nausea/vomiting, or confusion.
 

Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. X-rays, gamma rays, and charged particles are types of radiation used for cancer treatment. The radiation may be delivered by a machine ousted the body (external-beam radiation), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy or brachytherapy), or it may use radioactive substances, such as radioactive iodine, to travel in the blood to kill cancer cells (systemic radiation therapy). The role of radiation therapy may include as a primary treatment; to follow surgery to prevent recurrence of cancer; in combination with chemotherapy; to provide palliative care-focus on relieving symptoms and improving quality of life.

Consultation: Your first visit to radiation oncology is a consultation with your care team including your physician, and a registered nurse. You will not receive radiation treatment at your first visit. Plan to be in the clinic for two or more hours. This is an important visit to learn about your medical history and treatment needs. For most patients, the visit will include physical examination, review of medical history, medications and CT/MRI, and other imaging. After this visit, you may be scheduled to start the radiation process. 

Simulation: If it is determined that you will start radiation therapy, there are many steps in preparation for your start date. For most types of treatment, a simulation (SIM) appointment will be scheduled. The purpose of this visit is to outline or map the exact area to be treated. A CT scan will be taken to verify the anatomy and assure accuracy. If needed, immobilization devices such as a face mask or a leg mold will be made at this time. Your skin will be marked with small dots of permanent ink (tattoos) to ensure that eh precise area is treated each time. The SIM visit takes about one hour. During the SIM visit, the radiation therapist will discuss treatment times and reserve a space for you depending on how many treatments you will be receiving.

Treatment Planning: After simulation, you will have a few days to a few weeks to relax while your radiation oncologist creates a unique plan of treatment taking into account your diagnosis, the type of machine that will be used, the amount of radiation needed and the number of treatments to be given.

Radiation Treatment: The number of treatments prescribed will vary depending on your specific cancer type and its location. Your experience may be completely different from that of other patients and may differ from previous radiation treatment you may have had. There are many different radiation therapy options, and the radiation oncologist will discuss with you the most appropriate plan. A full course of therapy may take several weeks, while other treatments may be one day or just a few days. Treatments are given Monday through Friday for the number of visits determined during planning. Typically, your treatment is scheduled for the same time each day. A licensed radiation therapist will administer your treatment.

Follow-up Appointments: When your course of treatment is completed, your radiation oncologist will need to see you for follow-up visits. You will be given instructions about the intervals at which you will need to be seen, and you can make your first follow-up appointment when you complete treatment.

NHO does not provide radiation therapy but they will arrange for your referral to a local radiation clinic if it is indicated.
 

Cancer surgery is the removal of the tumor and surrounding tissue during an operation. Surgery is the oldest type of cancer therapy and remains a very effective treatment for many types of cancer.

The goals of surgery include: to diagnose the cancer; to remove all or part of a tumor; determine where the cancer is located; determine if the cancer has spread or is affecting the functions of other organs in the body; restore the body’s appearance or function; relieve side-effects.

For most types of cancer, a biopsy is the only way to make a definitive diagnosis. During a surgical biopsy, the surgeon makes an incision (cut) in the skin and then removes some or all the suspicious tissue. After a biopsy, a pathologist (a doctor who specializes in interpreting laboratory tests and evaluates cells, tissues, and organs to diagnose disease) uses a microscope to examine the tissue removed.  

Staging surgery is performed to find out the size of the tumor and if or where it has spread. During this surgery, the physician may remove some lymph nodes (tiny, bean-shaped organs that help fight infection) near the cancer to find out if it has spread. Your healthcare team uses the results from this surgery along with the results of other tests to guide the treatment options. These tests can also help predict a patient’s prognosis, which is the chance of recovery.

Tumor removal, also known as primary or curative surgery, is commonly used to remove the tumor and some of the surrounding healthy tissue (called the margin). Tumor removal may be the only treatment, or it may be combined with chemotherapy or radiation therapy.

Clinical trials are studies conducted to discover new and better treatments for diseases. 

Studies often compare study drug(s) that are drugs that have not yet been approved for use by the FDA to the current standard treatment to see if the study drug is more effective than the current standard treatment.  

Studies may also check to see if the study drug is at least as effective as the current treatment but has fewer side effects. 

All current treatment medications were once part of a clinical trial and have gone through the study process prior to being approved for use.

Our physicians and research department offer the opportunity to participate in clinical trials that are appropriate for the patient’s disease and overall health status. 

If any NHO patient appears qualified for one of our current open studies, the study information and opportunity would be presented to the patient. 

• It is completely up to the patient whether they participate or not. 
• The patient will not be penalized in any way if they decide not to take part in a study. 
• If a patient does start on a study and later decides he/she no longer wants to take part, they are free to withdraw from the study at any time. 

Studies may help pay for some of your treatment medical expenses, such as labs, x-rays, office visit charges, etc. Any procedure required by the study, that is not something that your doctor would order as part of your care if you were not on the study, will be paid for by the study. The study drug (not approved for use yet) will be provided by the study free of charge. 

There are different phases of clinical trials, phase I thru phase IV:  
Phase I studies: 

• Phase 1 studies are not conducted at NHO 
• This phase of study is conducted in laboratories and on animals prior to being conducted on humans. 
• Once they are conducted on humans, they involve a very small number of patients, looking at side effects and dosing.  
  • If the results are favorable, the drugs move on to Phase II study.

Phase II studies: 

• These studies involve a larger number of patients and are conducted primarily to find out safety information (side effects) and information on how the drugs affect the disease being treated. 
• Some drugs are approved by the FDA for use after phase II studies, some drugs must go onto a phase III study.

Phase III studies:

• Involve a larger patient population to confirm the information gathered during the phase II study, and to gather more information on safety and how the drugs affect the disease being treated.

Phase IV studies:

• Are conducted on drugs already approved for use by the FDA. 
• These studies typically do not dictate treatment or procedures but continue to gather more safety information on the drugs.

Our Oncologists are up to date on the most recent research findings and support research studies that may help our patients.   

For more comprehensive information on clinical trials:

National Cancer Institute at 1-800-422-6237 or check the website at clinicaltrials.gov.

Local sources of information include Nebraska Hematology-Oncology at 402-484-4900 or visit our Clinical Trials Web page where you can find further information on clinical trials conducted at our clinic. 
 

Central venous access devices (also known as vascular access devices or VADs) are used to provide access to your veins for the delivery of IV medications and chemotherapy and to obtain blood samples; they are for intermediate to long-term use; require minor surgery; and can stay in your body for an extended period of time (months to years).

Vascular Access Device (VAD) options used commonly at NHO

• Peripherally Inserted Central Catheter (PICC): Catheter made of soft, pliable material and is inserted into your arm vein, usually just above or below the bend of your elbow, and then threaded up into a larger vein in your chest. This catheter is used for short to intermediate use (weeks to several months). A doctor or specially trained nurse will place the PICC into your arm and will occur in the hospital or outpatient clinic. Using a needle, the PICC is inserted into a vein in your arm and from there, threaded into a larger vein near your heart (Superior Vena Cava). Once the catheter is in the correct position, the guidewire or needle is removed, and the PICC is left in place. The catheter site is stabilized with a securement device and a sterile dressing is placed over the insert site to protect it. An x-ray confirms the correct placement of the PICC. This procedure, while slightly uncomfortable, will not take long to perform, and you should not experience pain after the insertion is completed. The care of a PICC requires a sterile dressing change on a weekly basis and as needed. The PICC line will be flushed after each use or weekly if not in use and the injection cap at the end of the catheter will be changed at least weekly. The catheter site in your arm must be kept dry and the dressing must stay intact. 
• Implanted Port: A small vascular access device that is about the size of a quarter, with a hollow space inside that is sealed by a soft top. It is placed (implanted) under the skin, usually under local anesthesia, usually in the upper chest just below the collarbone, and is connected to a small flexible tube called a catheter. The tip of the catheter will be put into a large vein leading to your heart (Superior vena cava). Your port will look like a small, raised area under your skin. The center of the disk is raised and is called the septum. Fluids are put into or taken out of the port using a special needle (Huber needle) that goes into the septum. Most patients feel a mild prickling when the needle goes into their skin over the septum. When the port is accessed, it will be covered with a sterile dressing, when the port is not in use, no dressing is required. The catheter which is connected to the septum carries medicine or fluids right into the blood. Blood for lab tests can also be taken out through the catheter. When the needle is removed from the septum, no fluids or blood can leak out. The port will need to be flushed after each use or every four weeks if not in use. The sterile technique should always be used when your port is accessed. 
• Tunneled Catheter (i.e. Hickman, Groshong, or Apheresis): Catheter made of soft, pliable material; surgically inserted into one of the main blood vessels leading to your heart (superior vena cava) under local anesthesia. You may receive medications that make you sleepy during the procedure. A small incision is made near your collarbone after it is numbed with Lidocaine; this incision is called the insertion site. A second incision called the exit site will be made between your nipple and mid-chest. A tunnel will then be made under your skin between these two incisions and the catheter will be pulled through this tunnel from the exit site to the insertion site and threaded into a large vein leading to your heart. There will be a small Dacron cuff on the catheter between the insertion and exit site. The cuff serves two purposes (to help hold the catheter in place as your skin heals around it and to help prevent infections by stopping bacteria from entering the tunnel and traveling up to the vein). After the procedure, you will notice a dressing over the catheter exit site, this dressing will be changed 24 hours later, then every seven days or as needed (i.e. if soiled, loose, or wet). The catheter will be flushed after each use and daily or weekly depending on the type of tunneled catheter placed. The injection cap at the end of the catheter will be changed on a weekly basis. You will need to check your site every day to ensure that the dressing is intact (not peeling up) and check for signs of infection or vein irritation (redness, swelling, pain, or drainage).  

Important considerations for Central Vascular Access Devices (VAD):

• The choice of VAD should be based on the needs of the patient, the reason the line is required, and the length of time it needs to remain in place. After your VAD is placed, you will get a manufacturer's patient identification card with details on the type of VAD placed. Always keep this card with you. VADs, especially multiple-lumen devices, have an increased risk of infection, so lumens should be kept to a minimum when possible, accessed using sterile technique, and used when necessary (for needed therapy, for line maintenance, and for lab testing on days of treatment). If not necessary to use VAD, it is encouraged to use peripheral veins or fingers for lab testing on non-treatment/ non-maintenance days.
• Dressings used to cover the site should be maintained as appropriate for the type of line (kept clean, dry, and intact, not peeling up). Showering/bathing is allowed but dressing must be covered with plastic wrap (i.e. saran wrap) and secured in place with tape on all sides. Do not submerge the line in water even when covered with plastic wrap.
• Notify NHO immediately for any problems with your VAD: catheter accidentally pulls out (applies only to PICC or tunneled catheters), increased bleeding or drainage from the incisions or exit site, swelling of the face, neck, chest, or arm on the same side where the catheter was placed, increased bruising, tenderness or redness at the incisions or over the implanted port, fever of 100.4 degrees Fahrenheit or higher or increased pain.
• NHO appointment schedule: when you have a VAD, it is important to identify how the blood work will be obtained so that your appointment will be placed on the correct schedule. If you are coming in to see the provider and/or for infusion therapy, your VAD will be accessed and used. If you are coming in for VAD maintenance (depending on the type of line this may be a monthly VAD flush or a weekly dressing change and VAD flush), your VAD will be accessed and used. If you are coming in for lab only and you have a port, unless line maintenance is also required, you are encouraged to use your peripheral (arm) veins or a finger stick (this is a more timely and cost-effective method of use for the sole purpose of blood testing). If you have a PICC, it will be used for all appointment types. Please be on time for your scheduled appointments.
• Please know that if you are scheduled to have your lab drawn via your VAD, you are placed on the VAD schedule and if you are scheduled for venipuncture (via your arm or a finger stick); you are placed on the lab schedule. Different supplies, staff, and processes are used for VAD and venipuncture procedures. If we make changes to this schedule for last-minute requests, it will potentially cause a delay and increased wait time for you as there are existing scheduled appointments in each department that will have to be honored, and therefore your patience is appreciated.
   

Treatment consistency helps with treatment effectiveness

• When you arrive at NHO, check in at one of our kiosks. Please arrive on time for your appointment. If you have a lab appointment in addition to another appointment (seeing a provider or having chemotherapy or an injection), please arrive 20 minutes before your scheduled appointment time to allow time for your blood to be drawn.
• Stick to the treatment plan as outlined by your healthcare team.
• Inform your healthcare team of upcoming important events that may interfere with treatment.
• Discuss your concerns/questions with your healthcare team so they can assist you through the treatment process.

When talking with your healthcare team:

• Write down questions you have before you arrive for your appointments, so you don’t forget to discuss them with your healthcare team.
• Take down notes to help you to remember the information/instructions given to you.
• Ask questions and don’t hesitate to ask for clarification.
• Write down the date, the person you spoke with, and the answers to your questions.
• If possible, have a significant other accompany you to your visits; a second set of ears is helpful in capturing all the information given. Due to COVID precautions, only one guest is permitted at NHO right now.
• If you are calling in with a question or need, please keep in mind that your question will be typed up in your health record, discussed with a healthcare provider (Physician or Advanced Practice Provider) with a phone call back to review the explanation, or instructions. All calls will be triaged according to the urgency of the problem. A return phone call will be made the same day unless the patient and nurse agree on a next-day callback.

Important reminders during chemotherapy:

• Stay active within your physical limits.  It is important for you to continue to do the activities that interest you and keep you active.  
• Avoid infections.
• Avoid people with colds or other contagious illnesses.
• Practice good personal hygiene.  Wash your hands frequently, especially before eating and after using the restroom.
• Report signs of infection to your healthcare team promptly.
• Medications (prescription, over-the-counter medications, vitamins, herbal products).
  • Discuss with your healthcare provider before taking any non-prescription over-the-counter medications, vitamins, or herbal products.
  • If you are started on prescription medication by another healthcare provider (such as your primary care physician), please update your medication list at NHO.
• Changes to your medical or dental history.
  • Please notify your NHO healthcare team about any changes to your medical history (surgeries, procedures, radiology tests, immunizations, allergy or medication changes, or dental procedures).
• Nutrition and hydration are critical parts of your treatment.
  • Nutrition is very important to help your body handle the treatment of your cancer. You may not feel hungry, or food/liquids may not taste the same, but it is important to eat/drink well.
  • Refer to the information provided behind the nutrition tab in this binder. You may also refer to the American Cancer Society or the National Cancer Institute for nutrition information.
  • Depending on the problems you are experiencing, refer to suggestions in this binder for managing the loss of appetite, altered taste, nausea/vomiting, difficulty swallowing, and mouth sores.
• Report all symptoms altering your nutritional intake for further assistance.