Alopecia is the loss of hair associated with some chemotherapy agents. Many chemotherapy drugs are designed to kill rapidly growing and dividing cells, which means they attack health growing cells as well as cancer cells. Because hair follicles are fast-growing, many chemotherapy drugs cause hair loss. Loss usually occurs one to three weeks into the treatment, depending on the specific drugs being given. Once the hair begins to fall out, hair may simply become thinner or it may fall out altogether. Loss may be gradual or rapid, depending on the drug and it may involve scalp hair, facial hair, or other parts of the body. Fortunately, most of the time hair loss from chemotherapy is temporary. You can expect your hair to regrow three to ten months after your treatment ends, though your hair may temporarily be a different shade or texture. New hair might have a different texture or color, it may be curlier or straighter than it was before, or it could be gray until the cells that control the hair pigment begin functioning again. 

Many find comfort in wearing scarves, turbans, caps, wigs, or hairpieces. You may wish to purchase a wig or hairpiece before the hair loss begins so you are able to match it more closely to your own color and style.

• Contact your insurance company to verify that they will cover wigs (cranial prosthesis) and verify what information you will need to obtain reimbursement.
• It is perfectly acceptable to not wear any hair covering (wig, turban, etc.), as long as you are careful to protect your scalp from the elements such as sunburn.
• Use mild shampoo and conditioner and wash your hair less frequently.
• Limit the use of chemicals, hairdryers, rollers, curling irons or straighteners, and other styling aids.
• Avoid excessive brushing or combing. 
• Wear a warm hat at night when sleeping during the colder season. 
• Use sunscreen or wear a protective covering when you are outside.
• Some people choose to cut their hair short or to shave their heads before hair loss begins.  If you choose to shave your head, use an electric shaver to avoid cutting the scalp.
   

Red Blood Cells carry oxygen to the tissues in your body. Anemia is when you have too few red blood cells to carry the oxygen your body needs. Your heart works harder when your body does not receive enough oxygen. This can make it feel like your heart is pounding or beating very fast. Anemia can also cause you to feel short of breath, weak, dizzy, faint, or very tired (fatigued). Some types of chemotherapy cause anemia because of their effect on the bone marrow which is where red blood cells are produced. Your healthcare team will monitor your blood cell count throughout your therapy. If your red blood cell count falls too low, your doctor may prescribe a medicine to stimulate your bone marrow to produce more red blood cells or suggest you take iron or other vitamins or order a blood transfusion if indicated.

Helpful Hints:

• Get plenty of rest-try to sleep at least 7-8 hours per night. Take 1-2 short naps during the day as needed.
• Limit your activities-do only the activities that are most important to you.
• Accept help when family or friends offer!
  • Suggestions of help: run errands, pick up groceries, drive you to appointments, pick up your children, and assist with chores that you are too tired to carry out such as house cleaning or meal preparation.
• Eat a well-balanced diet
  • Calories will help maintain your weight
  • Extra protein will help repair tissues that have been harmed by cancer treatment.  
  • Talk to your healthcare provider about the diet that is right for you.
  • Make position changes slowly
  • If you are experiencing dizzy or lightheaded sensations, changing positions slowly helps your body to adjust. 
  • Examples: if lying down, sit for a moment before standing; if sitting, stand for a moment before you begin walking.

Report to your healthcare team: 

• Increase in fatigue
• Unable to perform your daily activities of living (bathing, dressing, eating)
• Feeling dizzy or faint
• Shortness of breath
• Heart pounding, or racing of heart rate

Good nutrition helps the body to rebuild tissue. Healthy eating habits are especially important during cancer treatment. Eating nutritiously can help you to more effectively cope with side effects and fight infection. Some types of therapy can make you to feel like you don’t want to eat. Feelings of depression or anxiety can also alter your desire to eat.

Helpful Hints when experiencing a loss of appetite:

• Eat small frequent meals
• If you are losing weight, high protein/calorie supplements (i.e. Ensure, Boost or like products) may be recommended to reduce weight loss or to maintain your weight
• Keep nutritious snacks on hand to eat throughout the day.
• Eat at a time during the day when you are feeling your best.
• Make your mealtimes relaxed and pleasurable; eat with family or friends; listen to music.
• Stimulate your appetite with a relaxing walk before mealtime or with other light activity.
• Serve your foods in an attractive and appetizing manner.
• Alcohol: check with your doctor before consuming alcohol; It may not be advisable for some patients.

Cancer-related brain fog initially termed “Chemo Brain” described by cancer survivors as memory problems that can occur during or after cancer treatment. For years, patients with cancer have complained of a mental cloudiness that they sometimes notice before, during, and after cancer treatment. Although the exact cause is not known, it can happen at any time and it is very real and now has been related to cancer and all treatments. For most patients, brain effects occur quickly but only last a short time. Others may have long-term mental changes. Usually, the changes that patients notice are very subtle, and others around them may not even notice any changes. However, the patients having the problems are aware of the differences in their thinking.

Studies suggest that there may be more than one cause of chemo brain, especially for the short-term symptoms. Along with chemotherapy, many different things can alter brain function and can include one or any combination of these factors: the cancer itself; other drugs used as part of treatment (steroids, anti-nausea or pain medicines); surgery and the drugs used during surgery (anesthesia); sleep problems; low blood counts; infection; fatigue; hormone changes or hormone treatments; other illnesses such as diabetes; nutritional deficiencies; patient age; depression; stress, anxiety or other emotional distress.

Symptoms of Chemo brain:

• Forgetfulness or memory lapses
• Difficulty concentrating or focusing on tasks
• Difficulty recalling or remembering common words or names
• Struggling to do more than one task at a time.
• Taking longer to finish things (disorganized, slower thinking and processing)

Helpful Hints:

• Exercise your brain.  Do word puzzles, take a class.
• Get plenty of sleep.
• Move your body.  Regular exercise is not only good for your body but also improves your mood, makes you more alert, and decreases fatigue.
• Use a detailed daily planner to keep track of appointments, schedules, “to do” lists, important dates, phone numbers, and addresses, etc.
• Keep track of your memory problems-include when you notice the problem, what is going on at the time, medicines taken, time of day it occurs.
• Try to not focus on how much these symptoms bother you.  Accepting the problem will help you in coping with it.
• Tell others-tell family, friends, and your cancer healthcare team about it.  Their support and understanding can help you relax and make it easier for you to focus and process information.
• You should not feel crazy or stupid; chemo brain is a side effect you can learn to manage.
• If brain problems cause you difficulty, talk with your physician to try and pinpoint what is causing your brain fog and what can be done about it.
• Write down questions about the problems you are having and take them to your appointment along with your memory tracking log to discuss with your healthcare team.  Take a friend or family member with you to help you keep track of what is said during the visit.

Constipation is a decrease in the number of stools. These stools may be dry, hard stools, and/or may involve increased straining with stool elimination. Some chemotherapy drugs as well as pain medications and anti-nausea drugs may cause constipation. This problem can also occur if your diet is lacking enough fluids and fiber or decreased physical activity.

Helpful Hints:

• Check with your physician to make sure it is okay to increase the fiber in your diet. 
  • Try foods such as whole-grain breads and cereals, dried fruit, wheat bran, fresh fruits and vegetables, dried beans, and peas. 
  • It is important to drink plenty of fluids with a higher fiber diet to help the fiber work.
• Increase the high fiber foods in your diet such as whole grain products, fresh raw fruits and vegetables, nuts, prunes, and raisins. 
• Drink plenty of fluids (1-2 liters per day). 
  • If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the amount of fluids you drink.
• Fresh fruit juices and warm or hot fluids are helpful.
• Increase physical activity as able. 
  • Exercise, such as walking, helps the stool move through the colon and helps prevent constipation.
• Use stool softeners or laxatives (as recommended by your physician). 
  • You may find using a combination of stool softeners and laxatives are most effective.  
  • Once you find a combination that works, continue on a daily basis as needed.
• Should you get diarrhea, stop the stool softeners and laxatives.  
  • Restart the drugs 24 hours after the last diarrhea episode and you may need to lower the dose.
• Notify the health team if you have not had a bowel movement in 3 days. 
• Rectal administration of enemas or suppositories should be approved first by your physician.  
  • When your white blood cells are low and you give medication rectally, there is an increased risk for infection.

Medications: (this should only be used after discussing first with your doctor and receiving their approval to use):

• Senna: over-the-counter medication that increases motility (movement) of the intestines. 
• Colace, Docusate Sodium: over the counter drug classified as a stool softener. This drug helps to draw moisture back into the stool. This makes the stool easier to pass.
• Senokot-S: this is a combination of both Senna and Colace.
• Milk of Magnesia: laxative, take as directed.

Treatment for cancer can affect the entire body, including your mouth. The oral (mouth) side-effects of treatment may include inflammation of the mucous membranes in the mouth (mucositis), taste alterations, infections, dry mouth, pain, tooth decay, sores in the mouth, and gum disease.  

• Good dental hygiene is especially important for people undergoing treatment for cancer.  
  • It is also important to have good communication with your dentist and your oncologist
  • You should inform your dentist about your cancer treatment, and you should inform your oncologist about your dental history and any planned dental work.

Important tips concerning dental health:

• Try to schedule a dental examination and cleaning before your cancer treatment begins and periodically throughout the course of your treatment. Regular dental hygiene is important for everyone, but because cancer treatments can affect teeth and gums, it can be even more important.

Daily dental hygiene should include:

• Brush your teeth and tongue, with a soft toothbrush, after each meal, and at bedtime.
• Floss gently once a day to remove plaque but avoid areas that bleed or hurt.
• Rinse your mouth often, with water, or bland rinses (adding salt/soda) to help keep your mouth moist, as many medicines can cause dry mouth, which can lead to tooth decay and dental problems.
• Avoid the use of mouthwashes that contain alcohol, as this can be drying to the mucous membranes.
• Use a mirror to check your gums and teeth daily for any changes such as bleeding gums, or sores.  If you notice a change or problem area, or experience pain in your mouth, report it to your healthcare team and your dentist immediately.

Osteonecrosis of the jaw (ONJ):

• Osteonecrosis of the jaw is an uncommon condition that may involve bone loss or breakdown of the jawbone.  
  • It can be a very serious condition.  
  • The symptoms include, but are not limited to; pain, swelling, or infections of the gums; teeth loosening; poor healing gums; numbness or a heavy feeling in the jaw.
• If you experience any of these symptoms or other dental problems, tell your oncologist and dentist immediately and follow your oncologist’s recommendations regarding your cancer treatment. 
  • You may be referred to an oral surgeon with experience in osteonecrosis.
• The diagnosis of osteonecrosis of the jaw may be made by x-rays or tests for infection (cultures).
• The treatment for osteonecrosis of the jaw may include antibiotics, oral rinses, and removable mouth appliances.  
  • Minor dental work may be indicated to remove injured tissue, but surgery is usually avoided because it may make the condition worse.
• The exact cause of osteonecrosis of the jaw is not known, but the disease has occurred in some cancer patients receiving a class of drug called bisphosphonates (Zometa), or Rank Ligand Inhibitors (Prolia and Xgeva).  
• Factors that may increase the risk for osteonecrosis include:  
  • Radiation, chemotherapy, steroid therapy, cancer itself, infection, history of poor dental hygiene, alcohol abuse or tobacco use, poor nutrition, and poor blood circulation

Dental Care:

• Dental care is an important part of your overall cancer care. 
• Be sure to tell your dentist that you are being treated for cancer. Update your medical history record with your dentist to include your cancer diagnosis and what treatments you're receiving. Provide both your dentist and oncologist each other’s name and phone numbers so they may consult with one another

Depression may be defined as feeling sad, disappointed, or upset, which may affect energy level, appetite, or sleep patterns.   

• Depression is fairly common among cancer patients and cancer survivors. 
  • Like cancer, depression is a disease that can quickly take over your life.  
  • Depression can be considered a cancer of the emotions-it invades your life little by little and before you know it your entire world revolves around the diagnosis.  
  • There are many factors that contribute to depression, including having your life threatened by a devastating illness, the financial burden of the disease, having to rearrange your life to undergo treatment, and the symptoms that cancer patients may experience such as pain, sleeplessness, and fatigue.  

Helpful Hints:

• Talk about your feelings. Being open can make things seem more manageable. Consider talking with your healthcare team so they can help you find ways to lessen your worries and fears.
• Depression among cancer survivors is common; your physician can easily refer you to someone that can help.  
  • Other help resources may include: 
• Support groups, family, friends, supportive networks, and clergy.
• Some symptoms of depression may include: 
  • Loss of interest or pleasure in activities, depressed mood, feelings of sadness/hopelessness/helplessness, difficulty sleeping, significant weight loss or decrease in appetite, fatigue or loss of energy, decreased or no interest in sexual activities, feelings of worthlessness, or excessive or inappropriate guilt, decreased ability to think or concentrate, recurrent thoughts of harming self. 
  • It is important to note any symptoms as well as how often is the symptoms present (most of the day, nearly every day). 
  • Identifying the early signs of depression may allow prompt treatment, which is the key to overcoming depression.
• Become educated about your disease, treatment, and possible side effects. Being knowledgeable and acting on that knowledge will help you feel more in control. Don’t hesitate to ask your healthcare team any questions you may have.
• Follow guidelines for managing fatigue as fatigue can affect your mood as well.
• If treatment for depression is needed, be patient as it may take weeks to notice improvement. Improvement may be seen in the following ways: better sleep; decrease in moodiness/grouchiness; ability to focus on tasks; ability to handle stress without over-reacting; ability to think positively; enjoyment of living.
• Depression can recur. Knowing the symptoms helps to recognize them.

Diarrhea is the passage of frequent stool, unformed or liquid in consistency, through either the body’s natural (anus) or diverted (ostomy) opening. Diarrhea is a symptom that may be caused by chemotherapy, radiation, medications, anxiety, or diet.

Helpful Hints:

• Drink plenty of clear fluids (1-2 liters or 8-10 eight-ounce glasses per day). 
  • Suggested clear liquids: Pedialyte/Gatorade, broth, jello, water.
• Eat small amounts of soft, bland, low fiber foods frequently.  
• Suggested foods to include in your diet: 
  • Bananas, rice, noodles, white bread, skinned chicken, turkey or mild white fish, crackers, applesauce, yogurt, mashed potatoes.
• Avoid foods such as: 
  • Greasy, fatty, or fried foods; raw vegetables or fruits; strong spices; whole-grain breads and cereals, nuts and popcorn; gas-forming foods and liquids such as beans, cabbage, carbonated beverages); lactose-containing products; alcohol.
• Avoid foods that are too hot or too cold
  • Extreme temperature may stimulate gastrointestinal activity.
• Record your bowel movements
  • keep a record of the number and the amount and character of your stools.
• Notify your healthcare team if you have an increase of 5 or more stools per day.
• Skincare: 
  • Clean the skin around the anus gently with warm water and soft cloth then pat dry.  
  • Apply a barrier cream such as Desitin to irritated skin. 
  • Allow the irritated skin to be exposed to open air when possible.  
  • Notify your healthcare team if you have tenderness or pain.
• Over-the-counter medication for diarrhea:  
  • Loperamide (Imodium)
  • Kaopectate
  • Maalox
  • Pepto Bismol.  
  • Read the label to make sure how to take the medication and discuss with your healthcare provider.  
  • If you have 5 stools despite the medication, notify your healthcare team.
• Suggested Imodium dosing:  
  • At the first sign of diarrhea take- 2 tablets (4 mg). During the day, take 1 tablet with each stool, as frequently as every 2 hours and during the night, take 2 tablets every 4 hours until morning. If after following this regimen, your diarrhea is not controlled for 24 hours, notify your healthcare team for further directions.
  • Note this dosage isn’t reflective in the package insert.

National Comprehensive Cancer Network defines Distress as:
“A multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can be disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. (p.DIS-2)

Symptoms of Distress may include:
- Overwhelmed to the point of panic
- A constant state of “dread”
- Sadness to the point of refusing treatment or unable to complete the treatment plan
- Unusually irritable & angry
- Unable to cope with symptoms
- Poor concentration
- Unable to make decisions
- Feelings of hopelessness
- Continuous thoughts of cancer and death
- Difficulty falling asleep, or early waking
- Difficulty eating, change in appetite
- Family conflicts without resolution
- Questioning of faith, & beliefs
- Feeling of worthlessness

Impact of Distress:
- Persons over all wellbeing!
- Decision making
- Cognitive functioning
- Employment
- Relationships
- Finances
- Coping

We understand that this disease affects patients as well as their entire family. Sometimes there is not a simple answer to your question, but we will provide you with as much information, and resources, to limit the impact of Distress on you, and your loved ones.

We follow Distress closely during your treatment at NHO. We not only want to lead your physical care and cancer treatment plan with awareness of your overall wellbeing of; body, mind, and spirit.

- A distress management screening tool will be utilized during your treatment to help monitor your level of distress and assist in the appropriate management, and resource referral.

Dysphagia is defined as difficulty in swallowing. The sensation of having the inability to pass food and liquids normally causes problems with a person’s ability to maintain adequate nutrition and a level of comfort as well as causes problems with the quality of life. Some cancers and their treatment can sometimes cause trouble with swallowing.

Symptoms of dysphagia may include: feeling of a lump in the throat with or without swallowing or always trying to clear the throat; dry throat; feeling that food gets stuck or the need to swallow food several times before the food goes down; burning sensation in the middle of the chest with or without swallowing; coughing/choking with foods or liquids; or liquids leaking from the nose; difficulty or pain with swallowing; choking/vomiting as a result of the inability to swallow food/fluids. It is important to discuss any symptoms you have with your nurse or physician. A referral to a speech pathologist may be needed so they can evaluate the problem and provide ideas on how to make your problems better.

Helpful Hints:

• Follow nutrition plan as developed by your healthcare team
• Follow exercise/safety plan as developed by a speech pathologist.
• Take medications as directed.
• Notify your physician if you experience coughing or choking symptoms while eating.
• Eat small, frequent meals.
• Sit upright while eating and remain in a sitting position for at least 30 minutes after meals.
• Do not smoke or drink alcohol.
• Avoid mouth rinses that contain alcohol.
• Use canned liquid nutritional supplements as needed.
• Eat soft or liquid foods may be helpful.
• If thin liquids are recommended, select from the following: coffee, tea, soft drinks, nutritional supplements, sherbet, broth, and thin cream-based soups.
• If thick liquids are recommended, select from the following:
  • buttermilk, eggnog, milkshakes, yogurt, shakes, and ice cream. 
  • There are products that can be used to thicken liquids such as: 
• Tapioca, flour, cornstarch, commercial thickeners, and baby rice cereal.
   

Everyone experiences tiredness; it is a universal sensation that is expected to occur normally at certain times of the day or after certain types of activity (exertion). 

• It usually has an identifiable cause, it is short-lived, and is relieved by a good night’s sleep. 
• In contrast to fatigue related to cancer
  • Is often described as a general, whole-body sensation that is unpleasant and abnormal or unusual
  • Not related to activity (exertion)
  • Difficult to identify the cause
  • Not easily relieved by sleep or rest. 
• Fatigue may be short-term (acute), lasting less than one month or more long-term (chronic), lasting anywhere from one month to six months or longer.
• Fatigue, acute or chronic, can have a profound, negative impact on the person’s quality of life by interfering in the ability to perform the kinds of activities and roles that give meaning and value to life. 
  • As a result, fewer activities are undertaken, and those that are performed may take 1onger to complete and require more effort. 
  • As fatigue begins to alter what patients can do for themselves, family members/ caregivers begin to assume many of the roles previously held by the patients. 
  • These increased role demands can then lead to fatigue in the family members/caregivers.

There are three types of fatigue:
1.  Neuromuscular fatigue involves the inability to move or use the physical body in the usual capacity.
2.  Attention fatigue is the inability to concentrate and direct attention for a period of time.
3.  Subjective fatigue describes any sense of unusual, abnormal, or excessive whole-body tiredness unrelated to any level of activity or exertion. All three types may be experienced at the same time.

Causes of fatigue:
While it is not completely understood why people with cancer experience this unusual fatigue, many factors are believed to contribute. 

• Changes in energy production and the availability of nutrients may cause fatigue. 
  • For example, the tumor itself may make the body function in an overactive state. Tumor cells compete for nutrients, often at the expense of the normal cell’s growth and metabolism. Losses in weight and appetite cab result in fatigue
• Disease complications and/or the side effects of treatment such as anemia, infection, and fever can create additional energy needs that usual food intake alone cannot supply.
  • Additional nutritional supplements and therapy may be needed. 
• Diagnostic tests, surgery, chemotherapy, radiation therapy, biotherapy, and drug therapies used to control symptoms/side effects of treatment, such as nausea, vomiting, pain, and insomnia, are associated with fatigue.
• Changes in activity or rest patterns can play a role in the prevention, cause, and alleviation of fatigue. 
  • Prolonged bed rest and immobility contribute to the loss of muscle strength and endurance. 
  • Muscle that is not exercised loses its ability to metabolize oxygen; thus, more effort and oxygen is needed to perform the same amount of work by conditioned muscles
• This is one of the reasons why aerobic, endurance exercise, such as walking 3-4 times a week for 20-30 minutes, often is prescribed for patients/family members.
  • Lack of restful or adequate sleep at night can lead to fatigue with;
• Increased sleepiness and napping during
  • Anxiety can contribute to sleeplessness; increased energy demands and fatigue.

What to do about fatigue:

• The best way to combat fatigue is to treat the underlying cause of the fatigue
  • Unfortunately, it is not always easy to know what the exact cause of the fatigue is. 
  • More commonly, multiple factors may be involved and require treatment, especially if the fatigue has become chronic. 
  • Chemotherapy can make you more tired than usual. 
• It is important for you to listen to your body and give it adequate rest. 
• Many patients will wonder whether they can continue to work. This is up to the individual. 
• Certain drugs will have greater effects on certain patients. 
• Our experience is that people do better when they stay involved in their day-to-day life. Be active but recognize that you may become tired more easily

Assessment

• Perform occasional “fatigue energy audits’’. Think about personal energy stored as a bank. Deposits and withdrawals need to be made over the course of the day, to ensure that a balance is achieved between energy conservation, restoration, and expenditure.
• Keep a diary for one week to identify the time of day when you are most fatigued or have the most energy and what are the contributing factors.
• Be alert to warning signs of impending fatigue such as;
  • Tired eyes, legs, whole-body tiredness, stiff shoulders, lack of or decreased energy, inability to concentrate, weakness, lack of motivation, sleepiness, increased irritability, nervousness, anxiety, or impatience.

Activity and Exercise Patterns

• Identify which activities or situations make your fatigue worse or better.
  • Develop a plan to pace yourself, scheduling activities according to your fatigue/energy patterns.
  • Try scheduling activities ahead of time during the day and throughout the week to avoid becoming unusually tired.
  • Pace yourself and plan adequate rest and sleep periods to allow full energy recovery before undertaking additional activities.
  • Deliberately select the activities that are most important for you to do or that give you the most pleasure 
• Do these activities first; let the other activities go or delegate them to someone else. Reduce unnecessary energy expenditure by using assistive equipment or by placing equipment and supplies within easy reach.
  • Adhere to some form of individually tailored exercise program approved by your physician. Walking is an activity that most individuals may be able to do at certain times during their illness and/or treatment. 
• Avoid exercising during the immediate 24 hours before and after your treatments or if you are running a fever, have low blood counts, or have disease involvement in your bones. Under these conditions, discuss further with your doctor.

Nutritional Patterns

• Drink at least 8 to 10 glasses of water to maintain hydration.
• Try to eat a balanced diet emphasizing complex carbohydrates (grains, legumes, vegetables) that provide a more sustained source of energy supply over time.
• Pursue dietary counseling; help with food preparation, shopping, etc., to further maximize and conserve your energy and to prevent your fatigue from becoming unusual, excessive, or chronic.

Distraction

• Use distraction techniques to focus on things other than tiredness, illness, disease, or treatments, such as listening to music, visiting with friends, watching television, and going for walk.
• Focus on those activities that may restore attention-depleting activities. 
  • These usually involve a change in activity or your daily routine (i.e., vary the stimuli and avoid boredom)
  • Activities that catch your interest easily, are enjoyable or at least pleasurable (i.e., appreciating nature, doing something creative such as drawing, writing, a hobby, or doing something socially with someone you find enjoyable).

Psychological
During this stressful time, it can be normal for patients and their family members to experience some depression.

• Use methods to alleviate some of the negative effects of stressors (i.e., exercise, progressive relaxation, visual imagery, meditation, prayer, talking with others, and therapeutic counseling).
• Do not focus on something for too long to avoid feelings of frustration. It is expected that during fatigue, mental alertness and direct attention capacities are low.
• If you still feel depressed talk to your health care team. 
  • They can help you find the resources you may need.

Rest and Sleep Patterns

• Set limits on visitors if you need to or have someone else “run interference” for you for a while when you need to rest and do not wish to be disturbed.
• Sit or lie down often. Short rest periods are better than long ones. Take naps as needed as long as they do not interfere with your normal sleep patterns.
• Adhere to or re-establish bedtime rituals that will help you to fall asleep (i.e., take a warm bath, have a bedtime snack or warm milk-which contains tryptophan, a natural sleep inducer, and avoid the intake of stimulants such as tea and coffee), stay asleep, and enjoy a good quality of sleep.
   

Recurrence is the return of cancer after your treatment has been completed.  This concern is very normal for cancer survivors, but there are many ways that a cancer survivor can overcome this fear and move on to a meaningful life.

Helpful Hints:

• If you have concerns about your cancer coming back, talk with your physician. 
  • Be informed about the early signs, how your physician plans to monitor you, and what you can do to improve your chance of living cancer-free.  
  • Survivors who are better informed may be more likely to follow a healthy plan of living.
• Take control of the things you can.  
  • The most important control you can take is to make healthy lifestyle choices.  
  • Living a healthy lifestyle can reduce the risk of cancer recurrence.  
  • Simply taking the following steps can make a big difference in overall health;
• Eat healthy foods; be physically active; maintain a healthy weight; don’t use tobacco products, and limit alcohol.
• Relax
  • Allowing fear to control you has been described as a type of emotional cancer and influences your ability to enjoy your life fully.  
  • Explore ways of letting go of the fear including exercise, counseling, support groups, and creative expression.  
• While this fear usually does get better with time, you can take action to deal with it early.
• Determine what triggers your fear.  
  • It may be an upcoming visit with your healthcare provider, having a new scan, noticing a new ache, pain, or a symptom similar to the one you experienced when you were diagnosed with cancer.  
  • Talk about your fear triggers with a significant other, a healthcare provider, or a counselor if needed.
• Don’t ignore new symptoms and keep your appointments with your physician.  
  • Report any worrisome changes in your body or new symptoms to your healthcare provider. By having your symptoms evaluated by your healthcare provider, it may be determined that it is not related to a cancer recurrence or if there is a recurrence, recognizing it early can lead to a better outcome.
• Taking action can make a difference!
   

Fluid retention is a buildup of fluid in the body caused by chemotherapy, hormone changes brought on by the treatment, or the cancer itself.  

• It can cause swelling or puffiness in your face, hands, and feet. 
• It can cause your stomach or lower part of your belly to feel swollen or bloated.  
• Sometimes the fluid builds up around your heart and lungs, resulting in coughing, shortness of breath, or an irregular heartbeat. 

Helpful Hints:

• Report to your healthcare provider if you notice swelling. puffiness, difficulty breathing or an irregular heartbeat.
• Avoid the use of table salt or salty foods.
• If you retain a lot of water, your healthcare provider may prescribe medicine to treat this.
• Weigh yourself at the same time of day, using the same scale, and report rapid weight gain to your healthcare provider.
• You can help minimize or decrease swelling in your feet and ankles by elevating them while you are sitting or lying down.
   

Some cancer treatments such as certain types of chemotherapy can result in infertility.  

• For a woman, this could mean that you may not be able to become pregnant.  
• For a man, this could mean that you may not be able to get a woman pregnant.  

Chemotherapy affects Women’s Fertility;

• May damage the ovaries.  
  • Decrease the number of healthy eggs in the ovaries.  
  • Decrease the hormones produced which can lead to early menopause.  
  • Early menopause and fewer healthy eggs can result in infertility. 

Chemotherapy effects on Men’s Fertility

• May damage sperm cells.  
  • Infertility may occur when the chemotherapy lowers the number of sperm
  • Cause sperm to move slower, or because other types of damage occur.
• Infertility depends on the type of chemotherapy you receive, your age, and other health problems
• Infertility can impact the future for that reason, before treatment begins, you should discuss your future wishes regarding having children, with your healthcare team.

Helpful Hints:

• Pregnancy Prevention
  • Your cancer treatment is not a form of pregnancy protection.  
  • It is not advisable to become pregnant or father children during cancer treatments.  
  • If you are sexually active and able to conceive or father children, you should use contraception.  
• Condoms are the most effective barrier protection and the least likely to interfere with other medical treatments or conditions.  
• Talk with your healthcare provider about what contraceptive methods are best for you.
• Protection from chemotherapy excreted in body fluids
  • Condoms provide a protective barrier to help prevent exposing your partner to chemotherapy excreted in your body fluids (recommended for a minimum of 48 hours after each chemotherapy treatment.
• Sexually Transmitted Disease (STD) Prevention
  • Not all contraception works to prevent sexually transmitted infections (STD).  
  • You may be at increased risk for an STD during or after your cancer treatment because your immune system is compromised.  
  • It is important to reduce/prevent your exposure to STIs.
• Future Fertility
  • Currently, we cannot say with precision, whether or not you will be temporarily or permanently infertile from your cancer treatments.  
  • For women, some cancer treatments may not immediately affect fertility, however, ovarian failure (premature menopause) may occur up to five years after treatment has been completed (factors to consider with this are: current age and type of treatment).
• Fertility Preservation
  • It’s important to have this discussion before the start of chemotherapy treatments
     

The potential for nausea or vomiting is something that frightens most patients. These temporary side effects can be a result of the tumor itself, or from radiation or chemotherapy. Nausea and vomiting patterns will vary from patient to patient. These different patterns include anticipatory nausea or vomiting, acute post-therapy, or delayed nausea or vomiting. There are some chemotherapy drugs that do not cause these side effects at all. Please keep in mind that if you know someone who experienced discomfort with their treatment, it doesn’t mean that you will have the same effects. Everyone will react differently but there are excellent anti-nausea medications available that provide a great chance of preventing nausea or vomiting associated with chemotherapy. The goal is to prevent nausea before it happens. Often your oncologist will prescribe some oral anti-nausea medications to take at home before you are sick or to treat nausea and vomiting promptly. In the office, medications will be given intravenously to prevent nausea and vomiting prior to treatments.

Helpful Hints: 

• Take prescribed anti-emetics at the first sign of nausea.
  • Anti-emetics can be taken prophylactically 20 minutes before meals 
• Eat slowly and chew your food well.  
  • Eat frequent small meals and snacks instead of large meals.
• Rinse your mouth often to eliminate any bad taste.
• Avoid strongly scented foods, which can bring on nausea.  
  • If the smell of food bothers you, ask others to cook for you.  Then let the food cool down before you eat it.
• Avoid sweets and fried, fatty, or hot and spicy foods.  
  • Eat bland foods such as crackers or dry toast or cereal.
• Avoid eating your favorite foods if you are nauseated so you don’t associate them with nausea.
• Frequently sip small amounts of fluid throughout the day instead of large quantities with meals.
• Avoid lying down for at least two hours after meals.
• Avoid eating a heavy meal right after your treatment.
• Breathe deeply and slowly when you are feeling nauseated.
• If you do vomit, do not eat or drink anything more until the vomiting is under control.
• An hour or so after vomiting, try taking small sips of fluid or sucking on ice chips.
• Foods and drinks that may be easy on your stomach:  
  • Clear broth, clear soda, cranberry or grape juice, tea, water, chicken that is boiled or baked without the skin, cream of wheat or rice cereal, crackers, oatmeal, pasta, potatoes without the skin, rice or toast, bananas, canned fruit, gelatin, popsicles or sherbet,  yogurt.
     

The nervous system is made up of two main parts: the central nervous system (CNS) consists of the brain and spinal cord; and the peripheral nervous system (PNS) which consists of the nerves outside of the CNS which carry information back and forth between the body and the brain. The PNS helps control movement and senses (touching, hearing, seeing, tasting, and smelling) and the functioning of the internal organs such as the stomach, lungs, and heart.

Some types of chemotherapy can cause damage to the nervous system. Many nervous system problems get better over time but may take up to a year after chemotherapy to resolve and some symptoms may last long term. Early treatment can help symptoms be manageable and may also prevent symptoms from worsening.  

It is important to report changes in the nervous symptoms promptly to your healthcare team.

• Symptoms to report include: 
  • Hearing loss (tinnitus); vison loss and or side-effects such as blurred or double vision; slurred speech or difficult expressing yourself or understanding speech; cognitive or thought-process changes including decreased memory, problem solving, and calculation; changes in taste and smell; difficulty swallowing; problems with balance, dizziness, nausea, and vertigo (feeling that room is spinning); problems with coordination and movement, including problems with posture, walking or holding objects; general weakness that causes an overall lack of strength, weakness on one side of the body or drowsiness; paralysis of different parts of the body (can range from one side of the body to a smaller areas like the facial muscles); seizures; changes in organ function such as constipation, inability to control flow of urine or impotence; pain from a tumor pressing on the nerve or damage to the nerves from treatment; peripheral neuropathy (condition caused by damage or irritation to the peripheral nerves resulting in numbness/tingling/burning of hands/feet or inability to pick up small objects or button clothing.

Helpful Hints:

• Report nervous system changes to your healthcare team immediately.
• Treatment may be prescribed by your healthcare provider depending on the symptoms.  
  • Medicines may be prescribed to treat nausea, vertigo, infections, inflammation and swelling, pain, depression, peripheral neuropathy.  
  • Treatments may be prescribed such as nerve blocks for pain relief; occupational therapy to maintain motor skills; physical therapy to improve physical strength, balance, coordination, and mobility; and speech therapy to improve speech.
• Safety
  • Use caution when handling knives, scissors, and other sharp or dangerous objects; avoid falling by walking slowly, hold on to handrails when using stairs, use non-slip bath mats in tub or shower; avoid the use of area rugs; wear sneakers or other footwear with rubber soles; check the temperature of bathwater with a thermometer to avoid burns; avoid burns or cuts while cooking; wear gloves when gardening, cooking or washing dishes; steady yourself with a can or another device when walking.
     

Neutropenia is a decrease in the number of white blood cells, called neutrophils. These cells fight infection. We can measure the white blood cells by performing a laboratory test called a Complete Blood Count (CBC). Chemotherapy drugs, some types of cancer, and radiation can cause a temporary decrease in the number of white blood cells, making you more susceptible to infection. Certain chemotherapy drugs cause suppression of the bone marrow where the white blood cells are produced. If the bone marrow is suppressed, the number of white blood cells may drop very low. Your bone marrow will begin producing blood cells again when the effects of the treatment wear off.

Common sites for infection:

• Mouth and throat:  
  • Good oral hygiene is important. 
  • Brush with a soft toothbrush and use floss gently.
  • Do not use mouthwashes with a high content of alcohol (alcohol can dry out your mouth)
• Ask about antibacterial mouth wash. 
  • Avoid the use of tobacco and alcohol. 
• Lungs and sinuses: (infection of nasal passageway): 
  • You may experience drainage or a productive cough.  
  • It is important to note the color of the sputum; yellow or green may indicate infection.
• Skin:  Keep skin clean and moist. 
  • Cracked skin is more susceptible to infection. 
  • Maintain good personal hygiene; wash hands before and after meals and after bladder and bowel elimination. 
  • Bathe daily. 
  • Keep wounds and sores clean and dry. 
  • Avoid animal scratches or injuries that may lead to infection. Keep nails trimmed, to avoid scratching. 
  • Use gloves when gardening
• Bladder:  You may experience frequency or burning. 
  • Drink plenty of fluids; At least 8-10 (8oz) glasses per day. 
  • It is important to empty your bladder every 3-4 hours.
• Perineal:  Use soft wipes instead of toilet paper
  • This avoids perineal irritation and potential infection.  
  • Use sitz baths for perianal irritation in the case of diarrhea.

Tips to prevent or decrease the risk of infections: 
Once you begin treatment, you cannot prevent your white blood cell count for decreasing; however, you can prevent exposure to infection-causing germs in your environment by following specific precautions including:

• Avoid people with contagious infections.
• Avoid changing cat litter boxes or cleaning bird cages, and fish tanks.
  • If unavoidable proceed with caution- wear gloves, and wash hands
• Avoid gardening or contact with potting soil and fresh flower arrangements. These carry a fungus called aspergillus which can cause a serious lung infection when your white blood cell count is low.
• Maintain good personal hygiene including good hand washing before and after meals and after bladder and bowel elimination.
• Maintain good oral hygiene including brushing teeth after meals.
• Get adequate rest

Monitoring for Signs of Infection:

• Your immune system may be compromised during chemotherapy due to fewer white blood cells that help fight infection. 
  • It is expected that approximately 7-l 4 days after chemotherapy, the white blood count will reach its nadir (low point). 
• It is at this point the person is most susceptible to infection. 
• Therefore, it is important that you take precautions to avoid infection and monitor for any signs that an infection may be developing. 
• It is crucial that you notify your health care team immediately.
• A fever can be the first sign that you have an infection. 
  • One of the most common signs of infection is an elevated temperature. 
  • Take your temperature if you feel warm or chilled.
  • If your temperature is above 100.4° you should contact your health care team immediately.
• Avoid taking products to reduce your temperature until speaking with a health team member.
• Often your physician will prescribe an antibiotic.
• By treating the infection promptly, most often hospitalization can be avoided.

Symptoms of infection that should be reported to your health care team:

• Temperature above 100.4 degrees Fahrenheit.
• New onset of cough or change in existing cough.
• Burning, increased frequency, or difficulty in passing urine.
• Redness, swelling, or tenderness around the area of the wound, sore, or catheter site.
• Chills, flushed feeling or shaking.
• Sore throat, white patches in your mouth, or open mouth sores.
• Sinus pressure and/or headache.
• Unusual vaginal discharge or itching.
• White patches in your mouth.
• A new skin rash.

Many patients and family members anguish whether to call the clinic or not! Especially noted off-hours, weekends. We’re your team and being proactive is the best treatment course to take.

• We want you to call at the first sign of infection.

Treatment:
Granulocyte Colony-stimulating factors: (refer to index tab for injections)

• Colony-stimulating factors are substances that stimulate the production of blood cells and promote their ability to function.  
• They do not directly affect tumors but through their role in stimulating blood cells, they can be helpful in supporting the person’s immune system during cancer treatment. 
• The use of growth factors (Neupogen or Neulasta)
  • The goal is to reduce the decline of white blood cells and minimize how long they remain low.
  • Keeping the white blood count in a normal range, infection is less likely to occur. 
• This enables the patient to continue with their chemotherapy schedule and helps to prevent unnecessary hospitalization and the need for IV antibiotics. 
  • These drugs may be ordered by your healthcare provider depending on the type of chemotherapy you receive, and its risk for causing neutropenia.  
  • If ordered by your healthcare provider, these drugs are given into the subcutaneous (fat) tissue, by your healthcare team.
     

Some types of cancer can cause pain and some types of chemotherapy can cause painful side effects.  These may include numbness, tingling, burning, or shooting pain in the hands and feet, mouth sores, headaches, muscle, and joint aches and pains, and stomach pains.  It is important to discuss your pain with your healthcare team.

Helpful Hints:

• Talk to your healthcare team about the pain you have-be specific and descriptive and include the following: 
  • Where your pain is located (what part of the body).
  • What does the pain feel like (sharp, dull, throbbing)?
  • Does the pain come and go or is it constant?
  • Rate the pain experienced 
• The pain rating on a scale of 0-10, with zero being no pain, and 10 being the worst pain you can imagine.
  • How long does the pain last (minutes, hours)?
  • What makes the pain better (medication, ice/heat, rest, etc.).
  • What makes the pain worse (activity etc.)? 
  • What medicines do you take for the pain (how much, how often, do they help, and for how long).
• Communicate with your family and friends about your pain-they need to know about your pain so that they can help you.
• Pain control
  • Take your pain medicine as ordered (some medicine should be taken on a scheduled basis and some taken as needed for break-through pain)
  • Don’t skip your pain medicine or wait until your pain is severe before taking medicine as this makes it harder to control the pain
  • Try other methods to assist with pain management such as relaxation, yoga, deep breathing, etc.  
• If the pain medicine is not working effectively or it was working but is not any longer
  • Discuss this with your healthcare provider, the medicine may need to be adjusted.
• Pain medicine very commonly causes constipation
  • A bowel regimen is important to prevent/control constipation which may include stool softeners or laxatives.  
  • It is very important to discuss this with your healthcare team and for you to monitor your bowels and report changes or difficulty with constipation management.
     

Research has shown that exercise to be safe during and after cancer treatment and can improve physical functioning and quality of life. Inactivity may result in loss of strength, function, and range of motion in a person with a chronic illness (an illness a person may live with for a long time, such as cancer). As a result of this research, your healthcare team at NHO urges patients to be as physically active as possible. Regular exercise is an effective way to counteract the negative effects of inactivity in chronic illness. Moderate activity is defined as activity that takes as much effort as a brisk walk.

Benefits of regular exercise for cancer patients:

• Maintain or improve your physical abilities.
• Improve balance, decrease the risk of falls and broken bones.
• Prevent muscle wasting due to inactivity.
• Reduce the risk of heart disease.
• Improve blood flow to legs and decrease the risk of blood clots.
• Reduce the risk of osteoporosis (weak bones that are more likely to break).
• Decrease dependence on others to do normal activities of daily living.
• Improve self-esteem.
• Reduce the risk of anxiety and depression.
• Reduce nausea, improve appetite, and provide better weight control.
• Reduce symptoms of fatigue.
• Improve overall quality of life.

There are many reasons for being physically active during and after cancer treatment and each person’s exercise program should be based on what is safe, effective, and enjoyable for that person.  

• You and your healthcare provider should tailor an exercise program to meet your interests and needs. 
• Be sure to get approval from your physician first, and if you are receiving assistance from specially trained professionals (physical therapist, exercise specialist), make sure they are aware of your medical history and any limitations, to recommend the type, duration, and intensity of exercise that is best for you.

Individual Exercise Program:  

• Several types of exercises can benefit your physical functioning and overall recovery. Types include:
  • Cardiovascular, conditioning, strengthening, balance, and flexibility.  
  • Self-monitoring during exercise is important.
• Heart rate/rhythm, breathing, and muscle strength, or soreness.
• Taking rest periods if noting changes with heart rate, shortness of breath, or feeling lightheaded/dizzy.
• Use caution resuming activities if rest doesn’t Aleve the symptoms.
• The goal is to have your exercise program help you maintain endurance, muscular strength, flexibility, and level of functioning.
• Exercise Safety and Precautions:
• Remember, you should always check with your healthcare provider before starting any exercise program.  Important tips to remember:
• Do not exercise if you have significant anemia (low red blood cell count).  
  • Your healthcare team will be monitoring your blood counts during your treatment, so ask them about the best time to exercise.
  • If you have neutropenia (low white blood cell count), or if you take medications that may decrease your ability to fight infection.
  • Limiting time in crowds to decrease your exposure
  • Practice good and frequent handwashing until your blood counts are at safe levels.
• Be cautious with exercise if your sodium and potassium levels in your blood are low (this can occur if you have increased diarrhea or vomiting).  
  • Your healthcare team will be monitoring your blood tests.  
• If you are experiencing increased fatigue and you don’t feel like exercising, try to do at least 5-10 minutes of light exercise, or stretching every day.
• If you have numbness in your feet or have problems with balance and are at an increased risk for falls
  • Referral to physical, or occupational therapy would be best to help you get started
• Do not do heavy weightlifting or exercises that put too much stress on the bones if you have osteoporosis, cancer in the bone, have nerve damage, poor balance, or weakness as this may increase your risk for injury or bone fractures (breaks).
• If you are taking blood thinners or if your platelets (blood-clotting cells) are low. 
  • Avoid any activity that increases your risk for falls or injury.  
  • Report bleeding issues to your healthcare team.
• Do not exercise if you are experiencing unrelieved pain, nausea/vomiting, or any other concerning symptom.  
  • Report these symptoms to your healthcare team.
• Do not exercise above a moderate level of intensity without talking with your physician. 
• If you have any exposed tubes: intravenous catheter in your arm, a Groshong catheter, or an accessed implantable port.
  • Avoid water exercises.  
  • Avoid resistance training that uses muscles in that area of the catheter to avoid dislodging it.
  • Talk with your healthcare team about what is safe for you.

Tips when planning an exercise program:

• If new to exercise recommended to seek assistance from a professional trainer, physical therapist, or programs geared to oncology rehabilitation to get you started.
• Start slowly with an exercise program and increase to toleration.  
  • Your muscles will tell you when you need to slow down and rest.
• Short periods of exercise with regular rest breaks.  
  • Examples walk briskly for several minutes, slow down for a minute, and walk briskly again until you have done 30 minutes of brisk activity.
• Try to include physical activity that uses large muscle groups. 
  • Strength, flexibility, and aerobic fitness are all important parts of an exercise program.
• Try to include some exercises that will help you keep lean muscle mass and bone strength, such as exercising with resistance or light weights.
• Always begin with warm-up exercises for about 2-3 minutes. End your exercise sessions with stretching or flexibility exercises.  Hold the stretch for about 15-20 seconds and relax.  Remember to breathe when stretching and exercising.
• Exercise moderately.  You want to increase your heart rate, but you also want to be cautious to not over-challenge your heart.
• Fatigue is very common in cancer patients on treatment.  
  • For some, fatigue is severe and limits their activity.  
  • Inactivity leads to muscle wasting and loss of function.  
  • An aerobic training program can help break this cycle.  
  • Research shows that regular exercise has been linked to reduced fatigue. 
• It has also been shown to improve your ability to do normal daily activities without major limitations.  
• Set up a daily routine that allows activity when you are feeling your best
  • Remember activities of daily living; shower, dressing, getting the mail, changing positions hourly help
     

Sexuality may be impacted by cancer through surgery that changes body image and alters function, treatment that decreases desire and/or function, and fatigue that commonly accompanies the disease and the treatment.  

• Intimacy, the closeness and sharing in a relationship that may or may not include sex, can also be altered following a diagnosis of cancer. 
• Certain types of chemotherapy can cause sexual changes.  
  • These changes are different for men and women.  
  • For women, chemotherapy can damage the ovaries, which can result in changes in hormone levels.  
• Hormone changes can lead to problems like early menopause or vaginal dryness.  
  • For men, chemotherapy can cause changes in hormone levels, decreased blood supply to the penis, or damage to the nerves that control the penis, all of which can result in impotence.  
• Whether or not you have sexual changes during chemotherapy depends on multiple factors such as: 
  • If you had these problems before treatment.
  • The type of treatments you will receive
• The type of chemotherapies
  • Your age and other illnesses can impact sexuality.  
• Some sexual changes may be long-standing, such as early menopause, and other problems such as loss of interest in sex, are likely to improve once chemotherapy is over.  
• Sexual dysfunction may also occur secondary to body image changes such as removal of a breast, amputation of a limb, or creation of a colostomy.

Sexual changes for women include:  

• Menopausal symptoms for women not yet in menopause (symptoms include hot flashes, vaginal dryness, irritable feeling, irregular or no menstrual periods); bladder or vaginal infections; vaginal discharge or itching; feeling too tired to have sex or having no interest in sex; feeling too worried, stressed or depressed to have sex.

Sexual changes for men include:  

• Inability to reach climax; impotence (unable to get or keep an erection); feeling too tired to have sex or having no interest in sex; feeling too worried, stressed, or depressed to have sex.

Helpful Hints for Women:

• Sex:  ask your healthcare team if it is okay to have sex during chemotherapy.  
  • Most women can have sex, but it is a good idea to ask.
• Birth control:  it is very important that you do not get pregnant while on chemotherapy.
  • Chemotherapy may hurt the fetus, especially in the first 3 months of pregnancy.  
  • If you have not yet gone through menopause, talk with your healthcare provider about the best birth control methods for you.
• Condom use while on chemotherapy:  
  • Some chemotherapy drugs can be present in small amounts in semen or vaginal fluids.  
  • To be safe, males should use a condom during the time the patient is receiving chemotherapy 
  • Avoiding intercourse until 48 hours after chemotherapy administered.
• Vaginal dryness:  use vaginal lubricants with sexual activity-choose a water-based gel that has no coloring, flavors, perfume or spermicide added as these chemicals may irritate genital tissues.  Examples are Astroglide, K-Y jelly, and olive oil.  
  • These products are applied before/during intercourse.  
  • Avoid products that are oil-based such as Vaseline as they may contribute to yeast infections.  
  • Prescription medication may be prescribed to help vaginal dryness such as vaginal hormones, discuss this with your physician.
• Vaginal moisturizers:  may be used 2-3 times per week to help keep the vagina moist and at a more normal ph.  
  • The effects of vaginal moisturizers last longer than vaginal lubricants.  
• Examples of this are Replens and Lubrin.  These products are used at regular intervals.
• Clothing:  wear cotton underwear; avoid tight pants or shorts
• Hot flashes:  
  • Dress in layers; stay physically active such as walking, biking, or other types of exercise; avoid caffeine; reduce stress with yoga, meditation, or other ways to relax; medication may be recommended to reduce the symptoms associated with menopause.  
  • Replacement estrogen therapy may not be recommended if the cancer is sensitive to estrogen such as tumors of the uterus, breast, and possible melanoma as estrogen therapy may make any remaining cancer cells grow.  
  • Discuss the risks and benefits with your physician.

Helpful Hints for Men:

• Sex:  ask your healthcare team if it is okay to have sex during chemotherapy. 
  • Most men can have sex, but it is a good idea to ask.  
• Condom use while on chemotherapy:
  • Some chemotherapy drugs can be present in small amounts in semen or vaginal fluids.  To be safe, you should use a condom during the time you or your partner is receiving chemotherapy (use for 48 hours after chemotherapy).
• Birth control:
  • It is very important that your partner not get pregnant while you are receiving chemotherapy (chemo can damage sperm and cause birth defects).
• Erectile dysfunction:  
  • It is important to discuss symptoms with your healthcare provider; prescription medications, external devices, or surgically implanted devices may be prescribed to help you achieve an erection.

Helpful Hints for all:

• Communication:  be open and honest with your partner about your feelings and concerns.
• Explore new ways to express love:  for instance, if you are having sex less often, you may want to hug and cuddle more, bathe together, give each other massages, or try other activities that make you feel close to each other.
• Communicate with the healthcare team:  if you or your partner is concerned about sexual problems, you may want to talk with someone who can help.  This may include your doctor, nurse, psychologist, social worker, marriage counselor, sex therapist, or clergy member.
   

Minor skin changes may occur in patients undergoing chemotherapy. Your skin may become sensitive to the sun causing you to burn easily. Other symptoms could include dryness, redness, itching, peeling, acne, or rashes. Your nails could become brittle, cracked, discolored, sensitive, or loosen and fall off. Some chemotherapy drugs may cause a darkening along the vein and some may increase the risk of sunburn when skin is exposed to sunlight. While these changes may be uncomfortable or annoying, most are minor and do not require treatment, and many will get better once you have completed chemotherapy. Major skin changes require immediate treatment. Radiation recall is a condition in which some chemotherapy causes the skin in the area where radiation therapy was delivered, to turn red (ranging from very light to bright red), blister, peel, and/or become very painful.  IV Chemotherapy leaking from a vein into surrounding tissues can cause symptoms ranging from none to severe tissue destruction depending on the type of chemotherapy. It is very important to report any swelling, tightness, burning, or pain at that IV site, immediately to your healthcare team. Allergic reactions to chemotherapy can result in skin changes such as immediate and severe itching, rashes, or hives along with wheezing or other difficulty breathing. You need to report any of the above symptoms immediately to your healthcare team.

Helpful Hints:

• Skin dryness:
  • Take showers rather than long hot baths.  Apply lotion while your skin is still moist after bathing/showering.  Avoid perfume, cologne, and aftershave lotion, as these contain alcohol and can be more drying to the skin.
• Hand-foot syndrome: 
  • Some chemotherapy agents can cause redness, skin peeling, cracking, or blisters on the bottom of feet and palms of hands.  
  • Notify your healthcare team if these symptoms occur.  
  • Moisturize hands and feet regularly with thick urea-based creams such as Udderly Smooth, Bag Balm, and Eucerin and wear socks and thin cotton gloves at night after applying the cream.  
  • Avoid extremes in temperature, pressure, or friction on hands and feet.  Limit exposure of hands and feet to hot temperatures such as baths, spas, washing dishes in hot water, etc. 
• For itching:
  • Apply cornstarch lightly to your skin.  Avoid extreme dryness (see above). 
• For acne:
  • Keep your face clean and dry.
  • Check with your doctor about using medicated creams or soaps.
• For nails:
  • Protect your nails by wearing gloves for dishwashing, gardening, or doing housework.  
  • Keep nails trimmed and clean.  Don’t push back your cuticles. Moisturize your hands and feet frequently with thick non-alcohol-based creams.  Do not bite your nails.  Do not wear nail polish, imitation nails or wraps until treatment is complete and nails have returned to normal. 
• Sun Exposure:
  • Use a sunscreen lotion with an SPF of 30 or greater.  Wear protective clothing such as hats or long-sleeved shirts.  Avoid excessive exposure to sun or tanning beds.
  • Notify your healthcare team if you should experience the following:
  • Sudden or severe itching. Skin rash or hives.  Skin infection such as redness or drainage.

Chemotherapy can cause sores in the mouth and throat, as well as cause the tissues that line the mouth, sinuses, and throat to become dry and irritated or to bleed. Mouth sores are not only painful but can become infected by germs that live in the mouth.

Signs of mouth sores include mild redness and swelling, a sensation of dryness, mild burning, and a decreased amount of saliva.

Helpful Hints:

• Check your mouth daily.
• Notify your healthcare team if you have difficulty eating, swallowing, or experience pain, or if you have white patches in your mouth.
• Brush your teeth with a soft toothbrush and non-abrasive toothpaste after each meal.
• If you have dentures, remove and clean them after every meal and at bedtime.
• Rinse mouth with a saltwater solution (the recommended baking soda solution is half of a teaspoon baking soda and half of a teaspoon of salt, in one cup warm water).  Hold and swish the solution in mouth for at least 30 seconds then spit.
• Avoid mouthwashes containing alcohol as this can dry out your mouth and make the mouth sores worse.
• Keep your lips moist with lip balm.
• Eat a well-balanced diet (include high protein, high caloric foods).
• Eat soft foods.
• Avoid the use of tobacco and alcohol.
• Avoid foods that are spicy or salty; citrus fruit and juices, and rough, coarse, or dry foods such as potato chips.
   

Taste alterations are defined as changes in the taste of foods. Taste changes can result from surgical procedures, radiation therapy to the head and neck area, and chemotherapy. 

• Commonly reported changes include a decreased threshold for bitter, beef, pork, chocolate, coffee, or tomato. 
• An increased threshold for sweets usually will lead the patient to add sugar to food, whereas a decreased threshold may cause an aversion to sweet foods. 
• Other taste changes include:
  • An increased desire for salt, avoidance of sour foods, or a metallic or medicinal taste. 
• For most patients, changes in taste will go away when the treatment is complete.

Each person’s response to treatment is individualized and therefore there is no foolproof way to prevent the changes from occurring. However, the following tips may be helpful, as well as discussing the problem with your nurse or physician.

Helpful Hints:

• Increase your fluid intake to two to three liters per day. Drink non-irritating liquids such as water, apple juice, grape juice, or sports drinks. 
• Suck on sugar-free candies to stimulate saliva production.
• Eat small frequent meals.
• Use plastic utensils instead of metal to avoid food tasting metallic.
• Eat sugar-free mints, chew sugar-free gum, or chew ice to mask the bitter or metallic taste.
• Substitute poultry, fish, eggs, peanut butter, beans, and dairy products for red meat.
• Marinate meats in sweet fruit juices, wines, salad dressing, barbeque sauce, or sweet and sour sauces.
• Flavor food with herbs, spices, sugar, lemon, and tasty sauce.
• Try tart foods such as oranges or lemonade.
• Chilled or frozen food typically is more acceptable to patients than warm foods.
• Brush your teeth before and after each meal.
• Avoid cigarette smoking.
• Control noxious odors in the environment.
• Choose and prepare foods that look and smell good to you.
   

Thrombocytopenia is a decrease in the number of platelets, a type of blood cell. Platelets are an important part of blood clotting. Some types of cancer, chemotherapy drugs, and radiation can lower the number of platelets. A low platelet count can create a potential to bleed more easily. Throughout your treatments, your healthcare team will monitor your platelet count.  If your platelet count becomes too low, your physician may postpone your treatment.  

Signs and Symptoms of a low platelet count: 

• Blood in your urine or stool.
• Bleeding from gums, mouth, or nose. 
• Bruising easily or several bruises from an unknown cause. 
• Fine pinpoint rash (petechiae), especially on the arms and legs.
• Vomiting or coughing up blood. 
• Headaches, dizziness, or fainting. 
• Sudden swelling or pain of a joint.
• Any bleeding that will not stop. 

Call the healthcare provider immediately if you experience any of the following: 

• Prolonged or unusual bleeding that does not stop after you have applied pressure. 
• Excessive bruising or petechiae.
• Blood in your urine or stool; coughing or vomiting blood.
• Heavier or prolonged menstrual periods, or bleeding between periods. 
• Persistent headache, blurred vision, or change in the level of consciousness such as excessive sleeping, confusion, or difficulty being awakened.

Helpful Hints to help reduce the risk of bleeding associated with thrombocytopenia:

• Brush mouth with soft bristle toothbrush. Keep lips moist with lip balm.
• Avoid mouthwash with high alcohol content. 
• Avoid activities that may cause injury to the skin. 
• Shave with an electric razor. 
• Avoid forceful nose blowing. 
• Avoid strenuous activity that may cause a fall, bruising, or injury. 
• Wear shoes, socks, or slippers to protect your feet. 
• Check with your healthcare team before having any dental work done.
• Avoid medications that may cause prolonged bleeding (aspirin, ibuprofen, and quinidine).  Check with your physician before taking any medications at home.
• Do not use suppositories or put anything in your rectum.  Avoid straining when you have a bowel movement.
   

Some types of chemotherapy can damage cells in the kidneys and bladder. The resulting problems may include: pain, burning, or frequency of urination; inability to urinate; inability to control the flow of urine from the bladder (incontinence); blood in the urine; fever, or chills; strong medicine odor; discolored urine (orange, red, green or dark yellow, this may be related to the color of the medicine dying urine the same color). Some kidney and bladder problems will go away after you complete your chemotherapy treatments and other problems may be long-lasting.

Helpful Hints:

• It is important to drink plenty of fluids-fluids will help flush the chemotherapy out of your bladder and kidneys.  Water is the best choice and 1-2 liters per day is usually recommended unless there are health conditions that would contradict this, discuss with your healthcare provider.
• Limit fluids that contain caffeine such as tea, coffee, and some soda pop.
• Your healthcare team will be monitoring your blood and urine throughout your therapy to monitor how your bladder and kidneys are working.
• Tell your healthcare team if you experience any of the problems listed above.
   

Xerostomia (hypo-salivation) is defined as dryness of the mouth. It can be a frequent complaint among the elderly, individuals with systemic diseases (i.e. diabetes mellitus), and patients undergoing radiation therapy for head and neck cancers or total body irradiation, a result of direct tumor extension and it is a side effect of multiple medications, including some chemotherapy agents. A dry mouth can make chewing and swallowing food more difficult and it can change the way foods taste.

Helpful Hints:

• Carry a water bottle with you throughout the day. 
  • Drink frequently throughout the day. Drink at least one to two liters of fluid per day.
• Suck on sugarless hard candies, popsicles, or chew sugarless gum.
• Try very sweet or tart foods and drinks such as lemonade as this may help your mouth make more saliva.
• Eat soft and pureed foods for ease of swallowing.
• Take small bites and chew your food well before swallowing.
• Limit caffeinated beverages such as coffee, tea, and soda pop.
• Moisten food with sauces, gravies, and salad dressings to make it easier to swallow.
• Keep your lips moist.
• Do not smoke or use alcohol.
• Maintain regular dental visits as needed.
• Assess your mouth daily. 
  • Report to your nurse or physician if you have: swelling or presence of ulcers (white patches).
• If dry mouth is severe, talk with your physician about products that help to coat/protect/moisten your mouth (artificial saliva).
• Perform oral care after each meal, at bedtime, and as needed. Use a soft-bristle toothbrush and use alcohol-free mouth wash. It is helpful to brush your tongue as well.