We would like to take this opportunity to share some helpful hints and information regarding the treatment room at VOA:

• Treatment times start at 8:30am. and are completed by 5:00pm. We request you keep your assigned time. If there are unplanned changes to your schedule, please contact us so we know those spaces are available for others.
• Space is currently at a commodity, so we appreciate limiting visitors to one per patient.
• No children under the age of 14 will be allowed in the treatment room. This is for their safety and to limit the patient’s exposure when their immune systems are more susceptible.
• There is coffee/water and crackers available. If other food is preferred you may bring your own. We also have volunteers from the Cancer Care Foundation of Tidewater that provide snacks during lunch hour. There is also a soda and snack machine in the waiting room.
• The sense of smell is unique to each patient on treatment. Please avoid bringing in foods with strong odors (i.e. fried foods, onions, and tuna) or wearing colognes as they can trigger episodes of nausea.
• The room temperature, as well as individual body temperatures varies. You may want to dress in layers to accommodate for those variances. Blankets are available.
• Please feel free to call nursing staff by their first names. We frequently call patients by their first names so if this is not preferred please let us know your preference.
• We will try to maintain your privacy and modesty so if you have a port or central line please wear button down attire and let us know if a private area is needed for access.
• Conversation is generally lively and for most all to hear. We request conversations with those patients around you pertaining to their health stay within the walls of the treatment room. We are bound by our respect for the patients and the ethics of our practice not to share information regarding other patients. We appreciate your concern for them but please do not ask us to give you information regarding them in return.
• Personal electronic devices with headsets are permitted. Wireless internet service is also available. Electrical outlets are extremely limited so battery operated devices are preferred. Please be certain to remember them when you leave!
• Magazines of various types are available for your reading pleasure.

It is our desire that each patient’s time with us be comfortable! If any situation arises that makes you uncomfortable, please do not hesitate to let the nurses or the nursing supervisor know at (757) 466-8683. Thanks for your participation in making the treatment room a comfortable and secure place.

Anemia is a decrease in the number of red blood cells (RBCs). Since chemotherapy destroys cells that grow at a fast rate, red blood cells are often affected. Patients receiving a combination of radiation therapy and chemotherapy are at greater risk for anemia. An important part of the RBC is hemoglobin, the part that carries oxygen throughout your body. Therefore, when your hemoglobin is low, oxygen levels are decreased and your body has to work harder in order to compensate. The end result is that your body will show signs of being very tired.

Normal hemoglobin levels for women are usually in the range of 11.8 to 15.5 gm/dL; for men, the normal level is from 13.5 to 17.5 gm/dL. While receiving chemotherapy/radiation therapy, your hemoglobin level may drop to lower than these normal levels, so your hemoglobin level will be checked periodically throughout the course of treatments. Any time that your hemoglobin level drops below 12.0 gm/dL, you are considered to be anemic.

• weakness or fatigue
• dizziness
• headache
• shortness of breath or difficulty breathing
• chest pain or palpitations
• irritability
• a heavy feeling in your upper legs
• ringing in the ears
• feeling chilled

What Can I Do to Prevent Anemia?
Since red blood cells are destroyed as a side effect of chemotherapy/radiation therapy, there is nothing specifically that you can do to prevent anemia from occurring. Anemia usually causes you to feel weak and tired; therefore, it is very important that when you are anemic you try to prevent your body from becoming extremely tired. Failure to do so may result in your becoming ill. Specific actions to take include:

• Get plenty of sleep.
• Avoid prolonged or strenuous activity.
• Pace yourself. Take rest periods during activities that make you feel tired. If necessary, take short naps throughout the day.
• Prioritize your activities so you will have enough energy for important activities or the activities that you enjoy the most.
• Ask friends and family to help you prepare meals or do chores when you are tired.

• Change positions slowly especially when going from lying to standing.
• When getting out of bed, sit on the side of the bed for a few minutes before standing.

• Eat foods high in iron, including green leafy vegetables, liver and cooked red meats.
• Drink plenty of fluids.
• Avoid caffeine and big meals late in the day if you're having trouble sleeping at night.
• Take iron supplements only if your oncologist or nurse practitioner/physician assistant has told you to do so.

When Should I Call My Doctor?
Call your doctor immediately if you have any one or more of the following:

• dizziness
• shortness of breath or difficulty breathing
• excessive weakness or fatigue
• palpitations or chest pain

How is Anemia Treated?
Depending on the cause and severity of the anemia, there are several ways that anemia can be treated. Your doctor may instruct you to take over-the-counter iron pills on a daily basis or may order blood transfusions.

Your doctor may also choose to order injections of a "growth factor" (Aranesp or Procrit). These substances work by stimulating the body's production of erythropoietin. An important growth factor used with cancer patients stimulates the growth of red blood cells. By increasing your body's production of red blood cells, this growth factor may decrease your risk of becoming anemic, and may also decrease the number of blood transfusions that may be required during your treatment. Your oncologist will talk with you and decide if this is the right treatment for you.

Neutropenia is a low level of white blood cells. Because radiation therapy and chemotherapy destroy cells that grow at a fast rate, white blood cells are often affected. Patients receiving a combination of radiation therapy and chemotherapy are at greater risk for neutropenia.

Since white blood cells play an important role in preventing infection, any time your white blood cell count drops, you are at higher risk of getting an infection. Since these cells also help to fight off infections once in the body, it may be harder to get over an infection when your white blood cell counts are low. Therefore, you need to take precautions to decrease the risk of infection while receiving treatment.

Your white blood cell count will be checked periodically throughout the course of your treatments. Any time that your white blood cell count drops below 1,000 per mm3, you will be considered neutropenic. Should this happen, a nurse will review with you special steps that you must take in order to decrease the chance that you will get an infection. These neutropenic precautions are discussed below.

What Can I Do To Prevent Neutropenia?
Since white blood cells are destroyed as a side effect of chemotherapy, there is nothing specifically that you can do to prevent neutropenia from occurring. Nonetheless, there are several things that you can do to reduce your risk of getting an infection when your white blood cells are low:

• Wash your hands frequently, especially before eating and after using the bathroom.
• Use alcohol-free, antiseptic mouthwashes daily.
• Do not cut or pick at cuticles. Use a cuticle cream instead. Even if you have a manicure, only cuticle cream should be used.
• Use a deodorant rather than an antiperspirant. Antiperspirants block sweat glands and, therefore, may promote infection.
• When menstruating, use sanitary napkins rather than tampons, which may promote infection in a neutropenic patient.

• Stay away from people who are ill.
• Avoid contact with anyone who has recently been vaccinated, including infants and children.
• Avoid crowds as much as possible. When going to places where there are often a lot of people (i.e., church, shopping), try going at off-peak times, when they are not as crowded.

• Always wear shoes to prevent cuts on your feet.
• Protect your hands from cuts and burns. When doing dishes, wear rubber gloves; always use potholders or some other protective covering when cooking or baking; wear gloves when gardening.
• Wear sunscreen with a sun protection factor (SPF) of at least 15 and avoid getting sunburned.
• Do not receive any vaccination, including the flu vaccine, unless your oncologist has approved it.
• Avoid activities that are prone to falling and/or injury, including but not necessarily limited to bicycling, roller-blading, skating, and skiing.

If you cut or scrape the skin, clean the area immediately with soap and water and bandage as necessary.

What Are Neutropenic Precautions?
If your white blood cell count drops to 1,000 per mm3 or below, you are considered to be neutropenic. Until your count rises, it will be necessary for you to take additional measures to further decrease your risk for infection.

• Take your temperature by mouth four times each day. Call your oncologist if your oral temperature is above 100.5o F.
• Eliminate uncooked foods, which may contain germs, including:
• raw meats or fish salads
• natural cheeses
• uncooked eggs
• fresh fruits/vegetables (if you can peel it, you can eat it)
• sushi and sashimi
• You may eat fresh fruits and vegetables if they are thoroughly washed.
• Avoid fresh flowers and plants, which may have germs in the soil.
• Avoid enemas, rectal suppositories and rectal temperatures.
• Unless an emergency, do not have any dental work performed. If you have an emergency that requires dental work, inform your dentist when you schedule your appointment that you are receiving chemotherapy. You may want to suggest that your dentist contact your oncologist prior to your scheduled dental work.

When Should I Call My Doctor?
Even if you have taken great care to prevent an infection, you may still become infected. If any of the following signs or symptoms of infection occur, call your doctor or nurse immediately. Do not take any medications, even aspirin or other products to lower your temperature, before talking to your doctor.

• oral temperature above 100.5o degrees, chills or sweats
• cough, excess mucous, shortness of breath or painful breathing
• soreness or swelling in your mouth or throat, ulcers or white patches in your mouth, or a change in the color of your gums
• pain or burning with urination or an odor to your urine
• change in the odor, character or frequency of your stool, especially diarrhea
• redness, pain or swelling of any area of your skin
• redness, pain, swelling in the area surrounding any tube you may have (e.g., Hickman catheter, mediport, feeding tube, urinary catheter)
• pus or drainage from any open cut or sore
• an overall feeling of being sick, even if you don't have a temperature or any other sign of an infection

How is Neutropenia Treated?
One of the most significant advances in the past decades has been the development of "growth factors," which stimulate the body's production of specific substances. One growth factor stimulates the growth of white blood cells and is used frequently with cancer patients, especially those receiving chemotherapy and radiation therapy. By increasing your body's production of white blood cells, this growth factor can decrease your risk of developing an infection.

Growth factors are administered by injection, usually 24 hours after your chemotherapy has completed.

If you develop an infection, your doctor will order medications to treat the infection. Depending on the cause and severity of the infection, the medications may be given either by mouth or through a vein using an intravenous (IV) catheter. If you require IV medications, accommodations can be made for you to receive them in our office or possibly at home. Some patients require admission to the hospital in order to effectively treat their infection.

If necessary, your oncologist may decide to delay further treatments until your white blood cell count has returned to normal levels and/or you are free of infection.

Low Platelets-Thrombocytopenia
Platelets are the blood cells that help the body to form clots. This is important to prevent bleeding from cuts or other injuries. Normal platelet counts usually range between 150,000 – 400,000 per mm3 of blood. Anytime platelets drop below 50,000 per mm3, there is an increased risk for bleeding. If platelets drop below 20,000 per mm3 and there are signs of bleeding, then you may require a platelet transfusions.

There are a number of causes for low platelets. Some patients have low platelets as a result of receiving chemotherapy; others may have autoimmune diseases or blood disorders. Whatever the cause of the low platelets, there are several precautions to follow to prevent injuries that may result in bleeding.

• Excessive bruising
• Tiny, pinpoint red spots on your skin (called petechiae)
• Bleeding gums
• Nosebleeds that do not stop
• Excessive bleeding from an injury that will not stop even after pressure has been applied
• Dark colored urine or blood in your urine
• Blood from the rectum, blood in the bowel movement (BM), or black colored BM
• Menstrual bleeding that is heavier than usual, lasts longer than usual, or occurs between periods

What to do to avoid bleeding

• Avoid strenuous activity, contact sports, lifting heavy objects, bending from the waist, straining to cough, blow your nose, or constipation.
• Avoid medications (see below) that affect blood clotting (unless approved by your doctor).
• Do not take aspirin or any product that contains aspirin. Check the labels of all drugs you are taking for salicylic acid, the chemical name for aspirin. If you are not sure about a drug or cannot tell by reading the label, check with your oncologist, nurse or a pharmacist. Do not take any non-steroidal, anti-inflammatory medications such as Motrin®, Aleve®, Advil®, etc. For headaches or other pain, use acetaminophen (Tylenol®).
• Avoid procedures that may cause a break in the skin. Avoid rectal exams, vaginal exams, vigorous thrusting during sexual intercourse, enemas, suppositories, douches, tampons, vaginal or rectal applicators, rectal thermometers, dental exams, surgeries, etc.
• Take special precautions with personal hygiene.
• Avoid falls in the shower or tub by using slip guard mats.
• Keep your teeth clean with a soft toothbrush. Do not use alcohol-based mouthwashes. Do not use dental floss. Keep your lips moist with lip balm to prevent cracking.
• Use an electric razor for shaving.
• Wear shoes to protect your feet.
• Avoid tight constrictive clothing or jewelry.
• Use stool softeners to avoid hard bowel movements that may cause injury to the rectum.

• Bleeding that does not stop after applying pressure for 15 minutes.
• Bleeding from the rectum, blood in the stool, or black stools.
• Blood in the urine or dark colored urine.
• A change in your vision.
• Persistent headache, blurred vision, or a change in your level of consciousness such as decreased attention span, excessive sleepiness, confusion, or difficulty being awakened.

*If you have a major injury or start spontaneous bleeding, go immediately to the nearest emergency room.

Does all chemotherapy cause hair loss?
Some, not all, chemotherapy drugs may cause hair loss. The type of chemotherapy regimen and doses prescribed will affect your chances of hair loss. Radiation therapy only causes hair loss in the area being treated. Hair loss typically starts 2-4 weeks after your treatments have started. You may experience thinning of the hair or complete hair loss. Hair loss can occur to all areas of the body including eyebrows, eyelashes, pubic area, facial hair, etc. If you are receiving chemotherapy, you should discuss whether or not the drugs you are receiving might cause hair loss.

Why does Chemotherapy cause hair loss?
Chemotherapy not only destroys cancerous cells but also affects healthy cells in your body. The healthy cells that are most at risk for being killed by chemotherapy are those which tend to grow at a fast rate, including hair cells. Thinning of hair and, in some cases, complete hair loss may result. Hair loss caused by chemotherapy is temporary.

What can I do if hair loss is expected with my Chemotherapy treatment?
Each person responds differently when learning that they may experience partial or total hair loss. There is no right or wrong response. What is important is to do what you feel comfortable with, to do what is right for you.

• If you plan to purchase a wig, make an appointment with a wig stylist as soon as possible. It is much easier to match the color and texture of your hair to a wig when your hair is still in place. When hair loss begins, it often progresses quickly and the wig stylist may have only your description of your hair and/or pictures as a guide. If hair loss begins before your appointment, save some pieces of your hair and take them with you.
• If a custom wig is too expensive, consider purchasing a less expensive, standard wig and having it professionally styled. Many wig salons offer this service, and the combined cost may be significantly less expensive than a custom wig. American Cancer Society and Cancer Action often have free wigs for patients.
• If your hair is longer, cutting it shorter may help to decrease the impact of your hair loss when it occurs.
• Some patients feel more in control if they shave their heads completely so they do not have to deal with the hair falling out. (Remember, baldheads are in style!)
• In addition to, or instead of, buying a wig, consider scarves, turbans and hats to conceal hair loss.
• Use a soft-bristle brush and a gentle, pH-balanced shampoo.
• Avoid harsh chemicals (color, bleaching, permanents). All of these may cause dryness/brittleness and may cause your hair to fall out faster.
• Sleep on a satin pillowcase to decrease friction.

Some insurance companies provide coverage for the purchase of wigs. Ask your doctor or nurse practitioner/physician assistant for a prescription. Check with your insurance company regarding coverage and limits. Keep in mind that the costs of wigs, scarves, false eyelashes, etc. are tax-deductible medical expenses.

What is Constipation?
Constipation is a decrease in the number of bowel movements and/or the difficult passage of hard stool that often causes pain, discomfort and sometimes bleeding from the rectum. In patients being treated for cancer, constipation can be caused by poor food and fluid intake, and decreased activity. Certain medications, especially pain medications, iron supplements and certain chemotherapy drugs can also cause constipation. Sometimes, the cancer itself, particularly cancers in the gastrointestinal tract, can cause constipation.

The signs and symptoms of constipation include: small, hard bowel movements, no regular bowel movement in 3 days, leaking small amounts of soft stool (like diarrhea) from the rectum, frequent and/or persistent stomach aches or cramps, passing large amounts of gas or frequent belching, bloated or enlarged belly, nausea and/or vomiting.

• Drink eight to ten 8 oz. glasses of non-caffeine fluids daily.
• Add prune juice to your diet. It has a natural laxative effect on the bowel.
• Increase the fiber foods in your diet (whole wheat bread and grains, fresh fruits and vegetables).
• Exercise daily. Even a short walk will be beneficial.
• Prevent constipation. If you are on pain medication, constipation is a side effect of the drugs because it slows down the bowel. Take a laxative daily when on pain medication.

Laxative Protocol
Patients should have a bowel movement at least every two days. Each patient will respond to his or her medication differently. We recommend using Senokot-S, Pericolace, ect. (over the counter medications). The generic forms work just as well.

• Take 2 laxative / stool-softener tablets at bedtime.
• If you do not have a BM by morning, take 2 more tablets.
• If you do not have a BM by evening, take 3 tablets, then repeat in the am.
• If there is no BM within 48 hours, take 2 tablespoons of Milk of Magnesia after breakfast and after dinner and continue with the Senokot-S or Pericolace.
• If there is no BM within 72 hours of starting this protocol, use a Dulcolax suppository or a Fleets enema (if your white cells are adequate).
• After having a good BM, use the previous step in your daily laxative protocol. For example if you achieve a BM with step 4 then use step 3 as your daily regime.
• If your stools get too loose then decrease the number of tablets to a comfort level

Do not take antidiarrheal medications!

What is Diarrhea?
Diarrhea is the passage of loose or watery stools three or more times a day that may or may not cause pain or discomfort in the abdomen and/or rectum. Patients with cancers of the gastrointestinal tract, including the stomach, colon and rectum often experience diarrhea. In addition, diarrhea may be a side effect of cancer treatment, especially chemotherapy and radiation therapy. Other common causes of diarrhea in cancer patients include bacterial and viral infections, anxiety, and nutritional supplement drinks (such as Ensure), which contain large amounts of vitamins, minerals, sugar, and electrolytes. Patients who are constipated may also have leakage of diarrhea. Because diarrhea can cause many problems, including loss of fluid from the body (dehydration), loss of important nutrients, weight loss, and fatigue, it should never be ignored or left untreated.

What Can I Do to Prevent Diarrhea?
The following information has been provided to help you manage and control this side effect.

Stop using Reglan, stool softeners, laxatives, or fiber supplements.

• Eat bland, low fiber foods such as the BRAT diet (Bananas, Rice, Applesauce, and Toast) boiled white rice, cheese, boiled chicken, and mashed potatoes.
• Choose foods high in protein, calories and potassium, and easy to digest such as cottage cheese, eggs, baked potatoes, cooked cereals, bananas, macaroni and pasta, white toast, and smooth peanut butter.
• Eat small amounts of food 5-6 times throughout the day, instead of three large meals.

• Greasy, deep-fried, fatty foods, and rich sauces because these may worsen diarrhea. Sugary or very spicy foods may also be bothersome.
• Sugar-free gums and candies usually contain sugar alcohols (sweeteners) that may cause diarrhea.
• Any foods that form gas will likely be a cause for diarrhea also. Some of these foods are: onions, beans, cabbage, peas, broccoli, cauliflower, whole grain breads and cereals, nuts, and popcorn.

Increase your fluid intake. Try to drink 3 quarts of fluid per day, unless your doctor or nurse tells you not to do so. This will help to prevent dehydration and malnutrition, which may result from diarrhea. Here are some specific suggestions:

• Do NOT drink coffee, tea, alcohol, milk or milk products, since they can make the diarrhea worse.
• Drink sports drinks, such as Gatorade, which help to replace some of the electrolytes lost in diarrhea.
• Drink clear liquids, including clear fruit juices (apple, cranberry, grape), ginger ale, and water.
• Drink liquids at room temperature.

Take over the counter anti-diarrhea medications if you are having more than 4 loose stools a day (or two more beyond what is normal for you). Imodium AD (or the generic equivalent) 2 tablets after the first loose stool, then 1 tablet after each loose stool up to 12 tablets a day until diarrhea stops.

Keep the rectal area clean and dry to avoid irritation and infection. Try using disposable washcloths (baby wipes) instead of toilet paper. Apply petroleum jelly to the rectal area (if you are undergoing radiation treatment to this area, then follow the radiation oncologist recommendations). You may use over the counter products for relief of hemorrhoid inflammation. Warm baths two to three times daily are very soothing. Sitz baths can be purchased at your local drug store

Do NOT smoke cigarettes.

When Should I Call My Doctor?

Diarrhea should not be ignored, since it can result in loss of fluid and nutrition and can be uncomfortable. Call your doctor immediately if you have any one or more of the following:

• 6 or more loose bowel movements per day for more than 2 days in a row
• blood in or around the anal area, in the stool, on the toilet paper or in the toilet bowl
• no urine for 24 hours
• inability to drink liquids for more than 24 hours
• fever
• weight loss of 5 pounds or more since the diarrhea started
• swollen and/or painful abdomen.
• Progressive weakness, dizziness, heart palpitations

Low Fiber and Low Fat Diet Suggestions
The following diet suggestions are made available to help you avoid foods that will cause bowel irritation and increase diarrhea. Making these changes in your diet can often control the diarrhea in mild cases. You do not need to start this diet until you are having increase stools (more than 2 over your normal).

Nausea is an uneasy feeling in the stomach that may or may not be followed by vomiting, in which the contents of the stomach are expelled through the mouth. Although many people connect nausea and vomiting with eating, nausea can happen even when a person is not thinking about food; and a person can vomit even when they have not eaten. The most common causes of nausea and vomiting are eating something that disagrees with you, or an infection or virus. In cancer patients, nausea and vomiting can also be caused by the cancer itself (especially cancers of the gastrointestinal tract such as the stomach, liver, and colon), by cancer treatments, especially chemotherapy and radiation therapy, or by other medications that may be given to cancer patients.

If nausea progresses to vomiting that cannot be controlled with the prescribed medications, notify the doctor or nurse immediately!

What Can I Do to Prevent Nausea and Vomiting?
There are a variety of things that you can do to prevent or minimize nausea and vomiting, such as:

• Prevent nausea by taking the antinausea medication prescribed by your doctor. Please follow the directions. Some medications are given to prevent nausea while others are prescribed to treat nausea.
• If you experience continual nausea, take your medication around the clock on a regular schedule.
• Eat lightly 1 – 2 hours before and after your treatment.
• Be sure to prevent or treat constipation or diarrhea. Some patients will become nauseated when their bowel is distressed. Notify the doctor or nurses if you are having problems with either one.

• Eat small amounts of food 5-6 times throughout the day, instead of three large meals. Keep crackers or bread within reach or at the bedside.
• Realize that taste changes may occur. DO NOT force yourself to eat favorite foods when you are nauseated. This could cause a permanent dislike of those foods.
• If you find that you do not like the taste of red meats, eat other high protein foods such as chicken and fish, cheese and eggs. Serve foods at room temperature to decrease the smell, which often contributes to nausea and vomiting.
• Eat foods with long lasting, pleasant smells such as lemon drops or mints. Using Ginger (hard candy, ginger root, ginger tablets, and ginger tea) may also alleviate nausea.
• Avoid foods that are sweet, fatty, salty, spicy or have strong odors because they may make the nausea and vomiting worse.
• If nausea and/or vomiting occur during your treatment, DO NOT eat for 1 to 2 hours before each scheduled treatment. If it occurs after your treatment, DO NOT eat for 2 to 3 hours after your radiation or chemotherapy treatment.

• Try to drink 8 to 10 ounce glasses of fluid per day, unless your doctor or nurse tells you not to do so. This will help to prevent dehydration and malnutrition, which can be caused by nausea and vomiting. Specific points to keep in mind include:
  • Drink clear liquids (liquids that you can see through when in a glass), including clear fruit juices (apple, cranberry, grape), ginger ale, and water. Sip the fluids slowly.
  • Popsicles, jello, ice chips and frozen juice chips are also excellent sources of liquid that are tolerated well because they are absorbed slowly.
  • Drink sports drinks, such as Gatorade®, which helps to replace certain electrolytes lost with vomiting.

• Maintain a quiet, restful environment whenever possible.
• If nausea and vomiting occur in anticipation of a visit to the doctor, or to receive a treatment, such as chemotherapy or radiation therapy, you may be experiencing “anticipatory nausea and vomiting”. This means that you have formed a connection in your mind between the event (seeing the doctor or receiving a treatment) and the nausea and vomiting. If this occurs, talk to your doctor or nurse, who will work with you to help prevent this from happening again.

• Maintain a quiet, restful environment whenever possible.
• Rest after meals. Sitting up for about an hour after meals is usually very helpful to lessen nausea.
• Take rest periods and naps throughout the day.
• Listen to soft music, watch television, read, or use any other form of distraction.
• Perform good mouth care frequently, especially after episodes of vomiting.

• DO NOT force yourself to drink fluids during periods of vomiting.
• DO NOT lie flat on your back during periods of vomiting. If you are unable to get out of bed, turn onto your side so that the vomit will not be inhaled or aspirated into the lungs.
• If vomiting frequently, do not eat for 4 to 6 hours, and then start with clear liquids.
• Since you should not take any over-the-counter medications while receiving chemotherapy unless approved by your doctor or nurse, DO NOT use over-the-counter anti-nausea medications (e.g., Pepto-Bismol®) until you have spoken to them. If your nausea and vomiting continues after trying these suggestions, contact your doctor or nurse so they can recommend additional steps.

Do not attempt to eat or drink if you are severely nauseated. Wait until your nausea is under control with the antinausea medications then attempt clear liquids.

When Should I Call My Doctor?
Nausea and vomiting should not be ignored since they can lead to dehydration and other complications, and can be uncomfortable. Call your doctor immediately if you have any one or more of the following:

• Blood in the material vomited.
• The material vomited looks like coffee grounds.
• You are concerned that some of the material vomited has been inhaled or aspirated into the lungs.
• You are not able to take more than 4 cups of fluid or ice chips in 24 hours, or are not able to take any solid foods for more than 2 days.
• You are not able to keep your medications down.
• You become weak or dizzy.
• You lose consciousness

Some patients may develop mouth sores (and sore throats) as a side effect from anticancer treatment. The severity of mouth sores may range from reddened areas with mild discomfort to white, ulcerated sores that are painful and require pain medication. The side effect is temporary and the mouth heals very quickly.

Patients receiving the chemotherapy agent 5FU may prevent or minimize mouth sores by chewing on ice 5 minutes prior to their treatment, through the treatment, and for 20 minutes following treatment. If your treatment is given in combination with Oxaliplatin, avoid food items that are cold, especially ice.

The following information may help minimize discomfort and promote healing of the mouth sores.

1. Keep your mouth and teeth (or dentures) clean. Brush your teeth (dentures) and tongue with a soft toothbrush and mild toothpaste 2 to 3 times daily. Do not use mouthwashes containing alcohol. If the toothbrush causes pain or discomfort, try soaking it in hot water to further soften the bristles. If still painful, use foam toothettes, which are available at most pharmacies or wrap gauze around a Popsicle(r) stick and gently swab the teeth and gums.

2. Keep lips moist with K-Y jelly or Chapstick®. Do not use Vaseline® because the oily base may promote infection.

3. Rinse and gargle at least 4 times daily with the following solution to keep the mouth clean and promote healing:
1 teaspoon of baking soda and 1 teaspoon of salt in 1 quart of water
(be sure to mix this fresh daily to prevent bacteria from growing in the solution)

4. Use a pain reliever. Such as Extra-strength Tylenol (acetaminophen) 2 tablets every 6 hours (unless instructed not to use this product by your doctor or nurse). If this does not relieve your pain so you can continue to eat and drink, contact the office for advice.

5. Do not use tobacco products or attempt to drink alcoholic beverages. These products dry the mouth and throat and increase the pain.

6. You must continue to eat and drink. If you cannot eat or drink you will become weak and have greater difficulty healing and be at risk for dehydration. The following suggestions may help you to continue taking in food and fluids.

Drink eight 8-oz. glasses of fluid daily. Avoid carbonated drinks, citrus or tomato juice, spicy drinks, or extremes of hot or cold because these will increase your discomfort. Limit caffeine to two cups per day.

Drinking through a straw may be more comfortable.

Avoid foods that will increase your discomfort such as: Spicy foods (barbecue, Mexican, Chinese), and acidic type foods (citrus, tomato base, vinegar base)

Eat soft foods or semisolids such as: cooked cereals with sugar and cream, soups (especially creamed soups), eggs, pastas, tender cuts of meat, potatoes, melon, canned fruits like peaches and pears, puddings, yogurt, ice cream, milkshakes (if the cold doesn’t bother you). Include foods high in protein such as dried beans, poultry, eggs, peanut butter, meat, fish, and dairy products, such as milk, cheese and yogurt.

When Should I Call My Doctor?
Mouth sores should not be ignored, since they can cause a decrease intake of food and fluid, can be a source of infection, and can cause pain and discomfort. Call your doctor immediately if you have any one or more of the following:

• Redness, shininess, or ulcers in the mouth that lasts for more than 48 hours.
• Bleeding gums.
• Oral temperature above 100.5°F, chills or sweats.
• Weight loss of 5 pounds or more since the mouth sores began.

How are Mouth Sores Treated?
To promote healing of mouth sores, your oncologist or nurse may recommend that you rinse with special solutions.

If mouth pain is severe or interferes with eating, your oncologist may prescribe a medication, which temporarily numbs the mouth. In addition, if weight loss from poor intake of food and fluids is a concern, you may be referred to a nutritionist.

If necessary, your oncologist may decide to delay further treatments until the mouth sores have healed.

If you have any questions about mouth sores, or need additional information and direction, ask your doctor or nurse.

What is Cancer-Related Fatigue? Cancer-related fatigue can cause a person to feel weak and to lose interest in people and daily activities. It is an overwhelming daily lack of energy that can have an impact on every aspect of a person’s life. Tiredness may be caused by the disease itself, or by medical treatments, like chemotherapy, radiation and surgery.

Cancer-related fatigue is not related to physical activity, nor can it be relieved with a good night’s sleep. If you have cancer and are experiencing fatigue, rest assured you are not the only one. The majority of cancer patients experience fatigue, and it has been found to be the most significant adverse effect of cancer treatment. Yet, fatigue remains one of the most overlooked and under-treated side effects of cancer.

What Causes Cancer-Related Fatigue?
Physical problems, mental stress or difficulties in your daily life can cause fatigue. The most common causes of cancer-related fatigue are:

• Anemia
• Anxiety
• Chemotherapy
• Depression
• Fever
• Infections
• Medications
• Nausea or vomiting
• Radiation
• Surgery
• Tumors

How Do I Know If I Am Fatigued?
Although fatigue does not affect everyone in the same way, there are some common ways people look or act when they are fatigued. The most common symptoms of fatigue include extreme weariness and tiredness. If you are fatigued, you may experience some of the following signs:

• Difficulty climbing stairs or walking short distances
• Difficulty paying attention or concentrating
• Shortness of breath after light activity
• Difficulty performing simple tasks such as cooking, cleaning or taking a shower
• Unable to do as much during the day as usual
• A desire to sleep more
• Slower speech
• Feeling like crying or depressed
• Paleness or shakiness

Simple Ways to Relieve Fatigue
To combat cancer-related fatigue, cancer patients must learn to conserve energy on a daily basis. Energy conservation plays a very significant role in managing fatigue. Fortunately, there are some simple things you can do to take charge of your life and minimize the effects of fatigue. Here are some recommendations:

Get Plenty of Rest
It is important to start and follow a normal and regular sleeping routine.

• Go to bed earlier and sleep later.
• Do not fight fatigue. Rest when you need it.
• Avoid drinking caffeine in the evening.

• Try to keep to a regular daily routine that is reasonable, but do not feel like you have to keep up with your normal activities.
• Limit and prioritize activities. Do the important ones first and decrease the number of less important activities.
• Accept offers from friends and family to help with chores.

Manage Your Stress
As a person with cancer, it is particularly important for you to get a handle on the stresses in your life. Take time to put them in perspective and work to eliminate unhealthy or unnecessary stress in your life.

Eat A Balanced Diet
It is important to eat the right foods that give you energy.

• Ask your doctor or nurse to refer a dietician, who can also give you helpful ideas.
• Eat a well-balanced diet with small, but frequent meals.
• Drinks lots of water throughout the day to help your body eliminate toxins.
• To avoid the fast-food trap, prepare balance meals ahead of time and freeze them.
• When preparing nutritious meals, double the recipe and freeze the extra portions for future meals.

Continue To Have A Social Life
To lessen fatigue, many people tend to let go of their social life and other fun activities first. While limiting your social life does conserve energy, it is important to do things in your daily life that make you happy. It is best to keep a balance between the activities you must do and those you love to do.

Exercise Daily
Regular, light exercise such as walking can significantly help to relieve fatigue.

• Plan to get some form of exercise every day.
• It is much easier to exercise when you enjoy it. Whether it is walking, bicycling or swimming, choose something you like to do.
• Talk to your doctor about the amount and duration of exercise that is appropriate for you.