Chemotherapy Class Participating in Your Care

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Chemotherapy ClassParticipating in Your Care

• A New Way of Caring
• Donna Hafner, RN, MSN, OCN, AOCNS
• Patient Educator
• www.VirginiaCancerSpecialists.com

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Participating in Your Care

• Class Objectives
• Provide you with a basic understanding of how
  chemotherapy works
• Explain the effects of chemotherapy on your blood
  cells
• Explain the common side effects that can occur
  during your chemotherapy treatment
• Provide you with information on how to manage
  your treatment side effects
• Provide you with resources and contact numbers to
  assist you during your treatment

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Participating in Your Care

• How to contact us
• Main numbers by office location
• Alexandria 571-483-1800
• Arlington office and infusion suite
  703-894-3800
• Fairfax 703-280-5390
• Gainesville 571-222-2200
• Loudoun 703-554-6800
• Woodbridge 703-986-1600
• Provide the following information when you call
• First and Last name (PLEASE SPELL YOUR NAME)
• Date of birth
• When you were treated/treatment you are receiving
• Reason for call
• Phone number where you can be reached
• After hours
• Dial the main office number
• Answering service will contact the on-call
  oncologist

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Participating in Your Care

• Pre-chemotherapy Recommendations
• Before treatment begins
• Fill prescriptions
• Port/central line placement if prescribed
• Order wig (prescription for cranial prosthesis)
• See dentist for cleaning/dental work if needed
• One to two days before each treatment
• Pre-chemotherapy lab work
• Follow-up appointment with oncologist or nurse
  practitioner
• Confirmation of appointment day and time
• Day before treatment
• Drink eight 8 ounce glasses of liquid the day
  before your treatment
• Take pre-medications as ordered if prescribed

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Participating in Your Care

• Day of treatment
• Drink two to three 8 ounce glasses of
  non-caffeinated liquids the morning of your
  treatment
• Eat healthy breakfast
• Wear comfortable clothing
• Take regular medications as ordered unless told
  otherwise by oncologist
• May take daily multi-vitamin, iron, calcium and
  vitamin D supplement
• Bring your treatment calendar and filled
  prescriptions with you to your first chemotherapy
  appointment
• Infusion nurse will review calendar and
  medications with you
• If you take pain medication for any reason bring
  pills with you to treatment
• Bring a lunch if your treatment is several hours
  or snacks if your treatment is shorter
• Make sure you have someone drive you to and from
  your treatment the first time and as needed

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Participating in Your Care

• During treatment session
• Wi-Fi is available for your convenience
• You use your I-Pod, portable DVD player, laptop,
  read a book, sleep etc.
• Blankets and pillows are available
• One family/friend may accompany/check on you
  during treatment session
• Space is limited in infusion rooms
• Cell phone use is permitted
• Ringer on vibrate
• Quiet conversation
• Limited connectivity in our building
• You can eat (snacks and drinks are available)
• You may use the rest room as needed

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Participating in Your Care

• General Recommendations
• AVOID
• Using perfume/cologne or scented lotions when
  onsite for treatment due to increased sensitivity
  to smell by others
• Aspirin unless ordered by physician
• Mega-doses of vitamins
• Any dosing above the daily recommended amount
• Alcohol intake 48 hours before, the day of and 48
  hours after or as long as you are taking
  anti-nausea medications
• Herbal supplements 48 hours before, the day of
  and 48 hours after treatment
• Always talk with your oncologist before taking
  any herbal supplements as these may interact with
  chemotherapy agents
• Resource National Institute of Health for
  Complimentary and Alternative Medicine
  http//nccam.nih.gov

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Participating in Your Care

• How is chemotherapy administered?
• Chemotherapy drugs can be given in one or more
  ways
• Intravenous (IV) through a vein
• Oral pill
• Injection shot
• Route of administration is based on
• Type of cancer
• Location of cancer
• Stage of cancer
• Effects of agents on normal body functions
• General health

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Participating in Your Care

• How does chemotherapy work?
• Affects cells that are rapidly dividing which
  includes cancer cells and some normal healthy
  cells
• Goal is to kill as many cancer cells without
  causing too much toxicity to normal healthy cells
• Normal cells affected by chemotherapy
• Blood cells (white, red, platelets)
• Digestive tract lining
• Hair follicles
• Reproductive cells

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Participating in Your Care

• Why are White Blood Cells (WBCs) important?
• Protect your body by fighting infection
• Normal White Blood Cell Count
• Total white blood count (WBCs)
• Percentage of all circulating WBCs
• Range 4.0 10.5
• Neutrophils (Granulocytes)
• Type of WBCs that fight against bacteria germs
• Absolute Neutrophil Count (ANC or GRAN)
• Percentage of neutrophils or granulocytes
• Range 1.5 6.6

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Participating in Your Care

• What happens if my neutrophils (type of WBC) are
  low?
• Increases your risk of infections
• An ANC or GRAN of lt1.5 is called Neutropenia
• Supportive therapy with growth factor
• Stimulates bone marrow to produce more WBCs
• Neulasta Injection
• Subcutaneous injection usually given the day
  after chemotherapy treatment
• Stays in your body for 14 days
• Neupogen Injection
• Subcutaneous injection given daily for 7-10 days
  usually beginning the day following chemotherapy
  treatment
• Bone aching is common side effect from growth
  factor
• Pain reliever can be used to treat unless
  contraindicated
• Antibiotics may be used to help prevent infection
  
• Chemotherapy may need to be delayed until WBCs
  increase to safe range

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Participating in Your Care

• How can I protect myself from infection?
• Prevention
• Frequent hand washing
• Use hand sanitizer
• Good oral hygiene
• Keep surfaces clean (door handles, counters,
  phone, keyboard)
• Wash, scrub, peel raw fruits and vegetables
• Use gloves when cleaning or outdoor work
• AVOID
• Being around people who are sick
• Children who have recently been immunized (Nasal
  H1N1, oral polio)
• Eating uncooked meats, fish and raw eggs
• Changing of litter boxes, birdcages, fish tanks,
  cleaning up animal waste (wear gloves if you
  must)
• Manicures, pedicures, acrylic nails
• Hot tubs and Jacuzzis

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Participating in Your Care

• What are the signs and symptoms of infection I
  should report?
• CALL TRIAGE NURSE or ON-CALL ONCOLOGIST if after
  hours if you experience
• Fever of 100.5 or higher or shaking/chills
• NEVER mask a fever with fever reducing medicine
• Other signs of infection
• Cough/sore throat
• Pain, burning on urination or blood in urine
• Diarrhea
• Abdominal pain
• Swelling or redness at surgical site or
  scrape/cut
• Vaginal itching or discharge

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Participating in Your Care

• Why are Red Blood Cells (RBCs) important?
• Carry oxygen throughout body and helps you feel
  energetic and remove waste products from bodys
  tissues
• Normal Red Blood Cell Count
• Red Blood Cells
• Male 4.5-6.0 M/ul
• Female 4.2-5.4 M/ul
• Hemoglobin protein on RBCs that carries oxygen
• Male 13-18 gm/dL
• Female 12-16 gm/dL
• Hematocrit measure of how much of the blood is
  made up of RBCs
• Male 42-52
• Female 37-47

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Participating in Your Care

• What happens if my RBCs are low?
• A decrease in RBCs is called Anemia
• Symptoms of anemia
• Weakness
• Fatigue
• Shortness of breath
• Rapid heart rate
• Dizziness
• Supportive therapy for symptomatic anemia
• Iron supplement if appropriate
• Blood transfusion
• Growth factor if appropriate

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Participating in Your Care

• Why are Platelets (Plts) important?
• Platelets are cells that help clot blood
• Normal Platelet Count
• 140,000 400,000
• What happens if my Platelets are low?
• A decrease in platelets is called
  Thrombocytopenia
• Symptoms of low platelet count
• Bruising/small red/purple pin sized dots on skin
• Red or pink urine
• Black or bloody stool
• Bleeding from your gums or nose
• Heavy bleeding during your menstrual period
• Headaches or changes in vision
• DO NOT
• Play contact sports or do activities where you
  could injure yourself
• Use tampons
• Use straight edged razor
• Supportive therapy for thrombocytopenia
• Platelet transfusion if below 20,000

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Participating in Your Care

• How are my blood counts monitored?
• Lab work is drawn at certain times during your
  treatment
• All patients must have labs drawn 1-2 days prior
  to each treatment cycle
• Types of labs
• CBC Complete Blood Count
• Drawn 1-2 days before each chemotherapy
  treatment and between cycles
• Measures your WBCs, RBCs, and Plts
• BMP Basic Metabolic Panel or
  
• CMP Comprehensive Metabolic Panel
• Usually drawn once a month or more frequently if
  regimen requires
• Measures your electrolytes (sodium, potassium,
  calcium, etc.)
• Measures your kidney and liver function

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Participating in Your Care

• What is a Nadir?
• Period after chemotherapy when your blood counts
  are at their lowest point
• Usually 7-14 days after chemotherapy
• Can vary depending on your treatment regimen

Chemo starts
Next Chemo cycle
Recovery Period
Blood counts decrease
Nadir 7-14 days
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Participating in Your Care

• Why is it important to stay on my planned
  chemotherapy treatment schedule?
• Your treatment regimen is planned to provide the
  maximum benefit for treating your disease based
  on dosing of the chemotherapy agents over a
  specified amount of time.
• What we planned vs. what you received
• Dose delays and/or dose reductions can impact
  treatment outcome
• Causes
• Low counts
• Illness
• Missed appointments

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Participating in Your Care

• Nutrition during treatment
• Make calories count
• Eat a well-balanced diet
• Protein is needed to help repair cells
• Stimulate your appetite
• Eat small frequent meals
• Keep snacks close at hand
• Try different flavors
• Choose foods that are easy to eat
• Eat food that are warm or at room temperature
• Avoid greasy, fatty or fried foods
• Tailor your diet as needed to meet your needs

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Participating in Your Care

• Common Side Effects from Treatment
• Loss of appetite
• Causes
• Chemotherapy agents
• Alterations in taste buds
• Metallic taste
• Alterations in smell
• Dry mouth
• Treatment
• Be open to trying different foods
• Add seasonings to food to increase flavor
• Eat small frequent meals
• Get daily exercise
• Drink 8-10 glasses of liquid a day
• Eat foods high in moisture (soups, casseroles,
  fruits)

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Participating in Your Care

• Nausea/Vomiting
• Cause
• Chemotherapy agents
• Treatment
• You will be given anti-nausea medication(s)
  through your IV before you receive your
  chemotherapy
• You will have oral anti-nausea medication(s) to
  take at home
• Take medications as prescribed
• Prescription medications you may be given are
• Prochlorperazine
• - Start with prochlorperazine, if not
  effective then take lorazepam if prescribed
• - Do not take prochlorperazine at
  same time as lorazepam
• Lorazepam/ATIVAN
• CALL TRIAGE NURSE if no relief or if
  nausea/vomiting persists after take anti-nausea
  medication(s)

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Participating in Your Care

• Mouth and Throat Changes
• Cause
• Some chemotherapy agents can affect the fast
  growing cells of the mouth, throat, lips which
  can affect your teeth, gums, lining of your mouth
  and the glands that make saliva
• Can cause increased sensitivity in mouth
• Treatment
• Maintain good mouth care throughout treatment
• Brush with soft toothbrush and gently floss teeth
  with waxed floss
• AVOID harsh toothpaste or mouthwash
• Use sensitive mouth products such as Biotene or
  Sensodyne
• Check your mouth and tongue daily
• Look for mouth sores or white patches
• Rinse mouth regularly with salt/baking soda
  solution to prevent infection and improve healing
  of sore mouth
• 8 oz warm water
• ¼ tsp salt
• ¼ tsp baking soda
• Eat high-protein foods that are soft and bland
• AVOID rough, sharp, spicy foods that can irritate
  mouth
• CALL TRIAGE NURSE if you develop mouth pain,
  sores or white patches in your mouth
• Magic Mouthwash may be prescribed

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Participating in Your Care

• Constipation
• Causes
• Medications
• Certain chemotherapy agents
• Pain medications
• Anti-nausea medications
• Changes in eating habits
• Decreased fluid intake
• Being less active
• Prevention
• Drink plenty of fluids
• Eat high-fiber and bulky foods
• Exercise/activities as tolerated

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Participating in Your Care

• Treatment for Constipation
• Add more fiber to your diet
• Take over-the-counter medications
• Fiber supplement
• Psyllium/METAMUCIL
• Stool softeners
• Docusate/COLACE
• Laxatives
• MIRALAX
• Docusate casanthranol/PERICOLACE
• Senna/SENOKOT
• Senna docusate/SENOKOT-S
• Magnesium hydroxide/MILK OF MAGNESIUM
• DO NOT use suppositories or enemas
• CALL Triage Nurse if no bowel movement in 3 days

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Participating in Your Care

• Diarrhea
• Causes
• Some chemotherapy agents onset 24-96 hours
  after chemo
• Certain foods
• Infection
• Treatment
• Drink fluids (water, clear broth, ginger ale,
  sports drinks)
• BRAT diet (bananas, rice, apples, toast)
• AVOID foods that exacerbate diarrhea (high-fiber
  and bulky foods, raw vegetables, fruits, caffeine
  etc.)
• Use over-the-counter anti-diarrhea medication
• Loperamide/IMODIUM AD
• Take 2 tablets after first loose stool and 1
  tablet after each additional stool up to 8
  tablets a day
• CALL TRIAGE NURSE if no improvement or you feel
  dehydrated

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Participating in Your Care

• Fatigue
• Causes
• Anemia
• Unknown mechanisms
• Treatment
• Listen to your body
• Rest when needed
• Stay active
• Keeps muscles toned (toned muscles require less
  energy)
• Increases sense of well-being
• Do activities requiring a lot of energy during
  periods of peak energy
• Usually early in the day
• Eat a well-balanced diet
• Maintain a sleep-wake schedule
• Wake-up/go to bed at same time each day
• Have bedtime routine and provide relaxing
  environment

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Participating in Your Care

• Hair Loss (Alopecia)
• Cause
• Some chemotherapy agents
• Hair follicles are rapidly dividing cells which
  are affected by chemotherapy agents
• What happens?
• Hair loss usually occurs 2-3 weeks after your
  first treatment
• All body hair will be affected
• Scalp ache usually occurs right before hair
  loss
• Hair will start to re-grow once treatment is
  finished
• Grows 1/2 inch per month
• Initial growth will be fine
• Texture and color may change
• Resources
• American Cancer Society
• www.cancer.org
• Look GoodFeel Better Program
• www.lookgoodfeelbetter.org

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Participating in Your Care

• Skin and Nail Changes
• Causes
• Some types of chemotherapy agents
• Symptoms
• Skin changes
• Dryness
• Itching
• Redness
• Peeling
• Photosensitivity to sun
• Can cause severe burning and blistering
• Darkening
• Increased pigmentation (melanin) along veins
• Acne
• Blemishes
• Increase potential if history of acne
• Nail changes
• Darkening of nail beds
• Usually occurs 2-3 weeks after treatment starts

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Participating in Your Care

• Skin and Nail Changes cont.
• Treatment
• Apply sunblock SPF 30 or higher on any exposed
  areas
• Reapply as needed
• Wear protective clothing including hat
• Avoid direct sun exposure as much as possible
• Keep skin clean
• Use moisturizer
• Do not use perfume, cologne or aftershave lotion
  that has alcohol
• Use products to strengthen nails
• Avoid acrylic nails
• CALL TRIAGE NURSE if you experience
• Severe sun burn or rash

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Participating in Your Care

• Eye Changes
• Causes
• Some chemotherapy agents
• Symptoms
• Trouble wearing contacts
• Irritation to eyes
• Blurry vision
• Clogged tear ducts
• Watery eyes
• Chemotherapy can seep out in your tears and can
  cause eyes to water more than usual
• CALL TRIAGE NURSE if your vision gets blurry or
  your eyes water more than usual

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Participating in Your Care

• Changes in Reproduction and Sexuality
• Sexuality changes
• Cause
• Chemotherapy can cause changes in hormone levels,
  body image and selfesteem
• Management
• Support a positive self-image
• Communicate with your partner and your
  oncologist/NP/nurses
• Reproductive changes
• Cause
• Chemotherapy can damage the reproductive organs
  affecting hormone, sperm or egg production
• Treatment
• Talk with your oncologist before you begin
  treatment
• May consult a reproductive specialist for
  fertility sparing options
• www.fertilehope.org for information on fertility
• Use contraceptive barrier throughout treatment
• Must prevent pregnancy during treatment
• Need to protect your partner from being exposed
  to chemotherapy

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Participating in Your Care

• Sleep Disturbances
• Types
• Insomnia (inability to fall or stay asleep)
• Disruption of sleep-wake cycle
• Excessive sleepiness
• Possible causes
• Emotional distress
• Experiencing side effects, especially pain
• Hot flashes/night sweats
• Chemotherapy drugs affect chemical balance,
  hormone levels
• Steroids
• Management
• Maintain wake-sleep routine
• Exercise
• Avoid stimulants late in the day, long naps,
  large meals at bedtime
• Sleep aids (discuss with oncologist or nurse
  practitioner)

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Participating in Your Care

• Cognitive Dysfunction
• Also called chemo brain or mental fogginess
• Difficulty with memory that may occur during and
  after cancer treatment.
• Causes
• Some chemotherapy agents
• Can affect be toxic to neurons or nerves in brain
• Bodys response to chemotherapy agents
  (inflammatory)
• Hormone suppression
• Other factors (i.e. anemia, fatigue, pain,
  nutrition)
• Unknown causes
• Symptoms
• Forgetfulness memory lapses
• Difficulty concentrating/staying focused on task
• Trouble remembering details like names, dates, or
  events
• Difficulty multi-tasking
• Taking longer to complete a task

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Participating in Your Care

• Treatment for Cognitive Dysfunction
• Talk with your oncologist or nurse practioner
• Treat underlying conditions if known
• Anemia
• Fatigue
• Pain
• Sleep disturbances
• Nutrition
• Exercise your brain
• Keep your mind active
• Stimulate your mind
• Train yourself to focus
• Develop ability to concentrate
• Establish concentration
• Increase concentration
• Set-up and follow routines
• Create notebook to keep papers organized
• Set-up calendar of activities/appointments
• Organize your environment

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Participating in Your Care

• Peripheral Neuropathy
• Condition where the nerves outside the brain and
  spinal cord (peripheral) are damaged
• Causes
• Some chemotherapy agents
• Radiation therapy
• Surgery
• Other health conditions such as diabetes
• Symptoms
• Usually occurs in hands and feet
• Tingling, burning, numbness, pain
• Difficulty with coordination
• Buttoning clothes
• Dialing phone
• Walking

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Participating in Your Care

• Treatment for Peripheral Neuropathy
• Report symptoms
• When it started
• Where it occurred
• How long it lasted
• Non-drug treatments
• Relaxation techniques
• Sit down when possible (if in feet)
• Treatment with medications
• Pain medications
• Steroids
• Antidepressants or anticonvulsants
• Effective in treating nerve pain
• Avoid
• Alcohol can further damage nerves
• High-blood sugar
• Bare feet
• Extreme temperature changes

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Participating in Your Care

• Frequently Asked
  Questions
• When will I see my oncologist?
• You should see your oncologist or the nurse
  practitioner as ordered usually about midway
  between each treatment cycle
• How should I prepare for my appointment with the
  oncologist?
• Write down any new or changing symptoms or side
  effects
• Write down your questions
• Check to see if you need any prescription refills
  and get them at the time of your visit
• When should I call the office?
• If you have a fever of 100.5 or higher,
  shaking/chills or have signs/symptoms of
  infection
• If you have side effects that are not being
  controlled with current prescribed therapies
• When do I have my labs drawn?
• CBC is approximately 2 days before each treatment
  cycle
• BMP/CMP are usually drawn once a month or more
  frequently depending on treatment regimen

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Participating in Your Care

• Additional services available
• Advanced Care Planning
• Helps ensure your care is customized to reflect
  your personal preferences, health needs, as well
  as meet your social, cultural and religious
  preferences
• Certified Nurse Practitioners available at all
  sites
• By appointment
• Genetic Services
• Genetic Screening
• Breast, Colon, Ovarian, Melanoma
• By appointment
• Genetic Counseling
• Certified Genetic Counselor
• Arlington and Fairfax Offices only
• By appointment
• Patient Benefits Specialists
• Contacts insurance company to verify benefits
• Helps you understand your benefits
• Answers questions regarding benefits

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Participating in Your Care

• Additional services available (cont.)
• Case Management
• Collaboration with insurance companies to help
  coordinate plan of care that has been decided by
  you and your oncologist
• Practice refers patient
• Patient consent obtained by insurance company
• Nurse from insurance company assigned to work
  with you
• Focus is on delivering personalized services to
  improve care by
• Coordinating ancillary services/resources
• Obtaining pre-authorizations
• Providing additional education
• Brochure available

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Participating in Your Care

• Helpful Resources
• VIRGINIA CANCER SPECIALISTS
• www.virginiacancerspecialists.com
• LIFE WITH CANCER (part of Inova Cancer Services)
• www.lifewithcancer.org
• 703-776-2841
• AMERICAN CANCER SOCIETY (ACS)
• www.cancer.org
• 1-800-227-2345 (1-800-ACS-2345)
• Local Office 703-938-5550
• NATIONAL CANCER INSTITUTE
• www.cancer.gov
• 1-800-422-6237 (1-800-4CANCER)
• AMERICAN SOCIETY OF CLINICAL ONCOLOGY (ASCO)
• www.cancer.net

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Participating in Your Care

• The staff at
• Virginia Cancer Specialists
• are here to help you.
• Thank you for attending!
• Please complete the
• class evaluation form.