Managing the Disease

month day, year • placeBeth Faiman RN, MSN, APRN-BC, AOCN

Nurse Practitioner, Cleveland Clinic Cancer Institute

Pre-Doctoral Research Fellow, Case Western Reserve

Cleveland, Ohio

Diagnosing and managing cancer is like a puzzle…. Many pieces to fit

-Help is needed from the healthcare team:… Doctors,…..Nurses……..And YOU!!!

I have cancer…. But I am not receiving treatment?

Some cancers have an initial “watch and wait” period:

- such as chronic lymphocytic leukemia (CLL)-“Indolent” lymphomas (waldenstroms

macroglobulinemia)-Smoldering Multiple Myeloma

Signs you will need treatment:AnemiaEnlarged lymph nodesFatigue, night sweats Tumors develop that affect body’s organs

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How Will Your Health Care Provider Decide on Treatment?

Treatment is individualized for each patient based upon:Physical exam and laboratory test resultsDisease stage, symptoms and complications

at time of diagnosisWhether the patient has been treated previously

for cancerAge and general healthLifestyle and quality of lifeInformation from current clinical trials

From International Myeloma Foundation. Multiple myeloma: patient handbook. 2006. IMF, North Hollywood, CA. www.myeloma.org

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Goals of Treatment

Stop disease from damaging organsExtend length of time without evidence of diseaseProlong life expectancyRelieve pain and other symptomsMaintain normal levels of activity and a good quality of life

What types of treatment will I receive

ChemotherapyDepends on cancer typeRituximab, bortezomibOral (by mouth) or Intravenous (IV)

ImmunetherapyRadiation therapy Surgery

In blood cancers this is rareSplenectomy if side effects of cancerLymph node removal if “bulky” tumor

Possible Side Effect of Treatment: Radiation

Radiation TherapyTreatment of choice for some tumors to kill or reduce tumor, relieve pain or

obstructionDestroy cancer cells with minimal exposure to normal cellsCells die or are unable to divide

DeliveryTeletherapy (external): radiation delivered in uniform dose to tumorBeam radiationBrachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds

Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others

Possible Side Effect of Treatment: RadiationGoals

Maximum tumor control with minimal damage to normal tissuesRARELY will patients receive implanted seeds or radioactive radiation - Caregivers must protect selves by using shields, distancing and

limiting time with client, following safety protocolsPrivate roomCaution sign on the door for radioactive materialDosimeter film badge by staffNo pregnant staffLimit visitors to ½ hour per day and keep them at least 6 ft from

the source

Possible Side Effect of Treatment: Radiation

Treatment SchedulesPlanned according to radiosensitivity of tumor, tolerance of client

Monitor blood cell countsOther Side Effects

Skin (external radiation): redness, burning Use mild soakDry skin with a patting motion, not rubbingDon’t use powders or lotions unless prescribed by radiologistWear soft clothing over the siteAvoid the sun and heat

Possible Side Effect of Treatment: Radiation

Mouth sores/mucous membranes: pain, lack of saliva (xerostoma)

Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation

Radiation pneumonitis1-3 months after treatmentCough, SOB, feverTreated with steroids to decrease inflammation

Possible Side Effect of Treatment: Chemotherapy

Many different types of chemotherapyAll have different side effectsMajor, common side effects will be discussed on the following

slides

RARE side effects of cancer or disease that are serious:Tumor lysis syndromeHypercalcemiaSpinal cord compression

Managing Side Effects of Chemotherapy Treatment

Gastrointestinal

Myelosuppression

Thromboembolic

Peripheral Neuropathy

Steroids

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Possible Side Effect of Treatment: Gastrointestinal (GI)

GI side effects can happen individually or in combination and commonly include:• Nausea• Vomiting• Diarrhea• Constipation

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Possible Gastrointestinal Side Effect of Treatment - Managing Nausea/Vomiting

• Concentrate on staying hydrated

• Eat before getting too hungry

• Eat bland food, cold or at room

temperature

• Find fresh air when possible

• Use relaxation techniques

• Try hypnosis or acupuncture

• Restrict fluids with meals

• Chew food thoroughly

• Suck on mints or hard candy;

popsicles or ice chips.

• Try peppermint or ginger tea

• Apply a cool compress to the

forehead, neck, wrists

Things that may help - Nausea and Vomiting

Medications to control nausea may be ordered by your health care provider. Take as directed.

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Possible Gastrointestinal Side Effect of Treatment - Managing Nausea and Vomiting

Things to avoid - Nausea and Vomiting

• Avoid strong odors• Do not lie flat after eating • Avoid sweet, salty, fatty,

spicy, heavy foods

• Avoid favorite foods (they may become associated with nausea or vomiting)

• Avoid citrus and tomatoes• Do not exercise after eating

If nausea and vomiting continue, your health care provider may add more anti-nausea medication and/or lower the

dose of treatment medication.

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Possible Gastrointestinal Side Effect of Treatment - Managing Diarrhea

Medications that may cause diarrhea• Laxatives• Antibiotics• Antacids with magnesium• Antidepressants• Prescription medications: check with your provider

Herbal supplements that may cause diarrhea • Milk thistle• Aloe• Cayenne• Saw palmetto• Ginseng

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Possible Gastrointestinal Side Effect of Treatment - Managing DiarrheaEating hints for diarrhea

• Increase fluid intake (water, Ricelyte ®, Pedialyte®, sports drinks, diluted fruit juice, and broth)

• Avoid caffeinated, carbonated, or heavily sugared beverages

Take anti-diarrheal medication• Imodium® or Lomotil® if recommended by a clinician• Fiber binding agents – Metamucil®, Citracil®

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Possible Gastrointestinal Side Effect of Treatment - Managing Constipation

Eating hints for constipation• Increase fluid intake• Drink warm/hot beverage prior to normal timing for bowel movement• Eat foods high in fiber, for example….

Other techniques to manage constipation• Ensure comfort, privacy, and convenience during bowel movement• Increase physical activity• Use stool softeners or laxatives or fiber binding agents – Metamucil®,

Citracil®

Contact your provider if symptoms continue. Your medications may need to be changed.

Possible Gastrointestinal Side Effect of Treatment – Managing mucositis Mucositis

Inflammation and ulceration of mucous membranes and entire GI tract

Rinse mouth with ½ normal saline and ½ peroxide every 12 hoursTopical analgesic medicationAvoid mouthwashes with alcoholAvoid spicy or hard foodWatch nutritional status

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Possible Side Effect of Treatment: Myelosuppression (low blood counts)

• The healthy bone marrow cells include:

– Red Blood Cells (RBC)– transport oxygen– White Blood Cells (WBC)– fight against infection– Platelets – protect against bleeding and bruising

• Affected by disease, myeloma treatment, and other medications or medical conditions.

• Decreased function of the bone marrow is called “Myelosuppression”

• Your health care provider will monitor blood counts regularly during therapy

Miceli, Colson, Gavino, Lilleby CJON Supplement, June, 2008. In press

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Anemia (low red blood cells)

Commonly seen with blood cancer. Result of decreased kidney function, cancer treatment or other medications.Symptoms of anemia

Fatigue, low energy level Unable to do regular activities Shortness of breath or chest pain with activity Pale appearance

TreatmentUse of red blood cell supplements, with cautionPossible red blood cell transfusion“Energy-sparing” activitiesReduced dose of medications

Miceli, Colson, Gavino, Lilleby CJON Supplement, June, 2008. In press

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Neutropenia (low white blood cells)

May be a result of cancer, treatment or other medications.The greatest concern with this side effect is infection. Symptoms to watch for –

Fever and shaking chillsDizziness or faintingRedness or swelling of skin or open woundRespiratory symptoms such as cough or sinus congestion

Precautions – Thorough hand washing to reduce contact exposureUse of mask as instructedAvoid crowds and potential contagionPreventative antibiotic therapy as prescribed

Miceli, Colson, Gavino, Lilleby CJON Supplement, June, 2008. In press

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Thrombocytopenia (low platelets)

May be a result of cancer, treatment or other medications. Watch for symptoms that may include

Frequent or large bruisesBlood in urine or stoolSpontaneous nosebleedsSmall red or purple spots on the body (petechiae)Bleeding that does not stop with pressure

To reduce risk of bleeding these practices are recommended:Do not take aspirin, ibuprofen or naproxen unless instructedAvoid activities that can cause bruising or bleeding such as contact sports

and heavy liftingMay need platelet transfusion at signs of bruising or bleeding or before any

necessary invasive procedure

Miceli, Colson, Gavino, Lilleby CJON Supplement, June, 2008. In press

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Possible Side Effect of Treatment: Deep Vein Thrombosis and Pulmonary Embolism

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) develop by a blood clot partially or completely blocking a blood vein or artery.

Risk factors for developing blood clots: - Multiple myeloma (cancer of the blood plasma cells) - Diabetes - Recent surgery - Immobility - Obesity - Smoking - Family history of clots - Current use of oral contraceptives or hormones - Cardiac problems - Varicose veins - Some combination treatments such as steroids with thalidomide or lenalidomide (for multiple myeloma)

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Possible Side Effect of Treatment: Deep Vein Thrombosis and Pulmonary Embolism

Symptoms of PE(spiral CT scan to diagnose)

Shortness of breath, difficult or labored breathingNew onset of chest or shoulder blade/arm painAnxiety Rapid heart rate

Report DVT and PE symptoms immediately

These events are considered a medical emergency and require immediate care

Symptoms of DVT(ultrasound to diagnose)

•Swollen, warm extremity•Dull ache, pain or tight feeling•Rapid heart rate•Abnormal redness of skin•Bluish color and cool skin

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Managing Side Effects of Treatment: Deep Vein Thrombosis and Pulmonary Embolism

Strategies to reduce risk of clots:Anti-embolism stockings (elastic stockings)Exercise regimenLow-dose aspirinMoving frequently when sitting long periodsTravel precautions (Foot/leg exercises, walking, ASA if not already

on blood thinner)

When taking Thalidomide or Lenalidomide, medications may be adjusted to reduce the risk of a a clot from occurring:

Lower drug dosesDifferent dosing scheduleBlood thinning with warfarin or heparin therapy

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Possible Side Effect of Treatment: Peripheral Neuropathy

Peripheral Neuropathy develops by injury, inflammation, or degeneration to the peripheral nerve fibers of one’s extremitiesSymptoms of peripheral neuropathy include:

Numbness Tingling Prickling sensationsSensitivity to touchMuscle weakness Burning Pain or Cold Sensation

Side effect of lymphoma, leukemia or myeloma treatment

Report symptoms of peripheral neuropathy to your health care provider early

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What to Do in Case of Numbness or Pain Due to Peripheral Neuropathy

If you experience numbness, tingling, freezing, throbbing or shooting pain due to peripheral neuropathy, you might:

Massage the affected area with cocoa butter regularlyTake B-complex vitamins (B1, B6, B12) supplementsGlutamineTake folic acid and amino acid supplements

If these symptoms worsen you should call your health care provider, who may recommend:

To stop treatment or reduce the dose of cancer treatment

A pain medication like gabapentin or Lidoderm® patchPhysical therapy

Proper management of PN will promote safety, increase mobility, and prevent unnecessary pain and

discomfort.

Possible Side Effect of Treatment – Managing Hair lossAlopecia

Hair loss2-3 weeks after treatment is startedAffects all the hair, including eyebrows, eyelashesWithin 4-8 weeks after treatment hair begins to grow backBefore hair loss, have the pt pick out a wig that is similar to hair

color

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Steroid Therapy

Steroids are a very important part of the treatment for lymphoma and multiple myeloma. Dexamethasone and prednisone are commonly used.Steroids target the myeloma cells for programmed cell death.Recent study using lower doses represented better overall survival and less side effects

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Potential Side Effects - Steroids: Increase in blood sugar levels – this can cause or worsen diabetesFatigue/HyperactivityDifficulty sleeping (Insomnia)Flushing/SweatingIrritability, mood swings, depressionIncreased in risk of gastrointestinal complications including stomach bloating, hiccups, heartburn, ulcers or gas.Body image changes - Weight gain, hair thinning/loss, skin rashesIncrease in blood pressure and water retentionIncreased susceptibility to infectionsSexual dysfunctionMuscle weakness or muscle crampingBlurred vision

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Managing Side Effects to Steroid TherapyThings to consider while taking steroids:Take with food Over-the-counter or prescription medications are recommended to prevent stomach discomfortSteroid schedule (am vs. pm)Medications to prevent shingles, thrush or other infections may also be prescribedReport signs and symptoms of infection (fever of more than 100.5 ° F, shaking chills even without fever, dizziness, shortness of breath, low blood pressure)

Do not stop or adjust steroid doses without discussing it with your health care provider.

LIVING WELL -Infections

Many people with leukemia, lymphoma and multiple myeloma are at risk for infections

Watch people with colds and coughsWASH your handsDiet???Notify your healthcare provider if you feel sickFLU vaccinePneumonia vaccineIVIG (Intravenous Immune Globulin)

LIVING WELL - Exercise

One of the single-most beneficial things you can do!!!!!!!!!

Prevents pneumonia and infectionsPrevents blood clotsMakes you feel betterIf you are on steroids – will strengthen your muscles and prevent weakness!Weight gain caused by steroids

LIVING WELL – Vitamin therapy

Not many herbals or vitamins have been tried in patients with blood cancers“curcurmin” – may take 500 mg a day (tumeric)Vitamin B6, B12-

May protect nerve endings from damage caused by cancer treatmentFolate – helps healthy red blood cells to form

LIVING WELL – Vitamin therapy

Green Tea – with antioxidants may stimulate the immune system in a positive way and allow you to fight the protein (caution with bortezomib (Velcade) for mantle cell lymphoma or multiple myeloma)

Always consult with your healthcare provider as to whether or not these are safe for you!

Psychosocial effects

Many cancer patients are clinically depressedMany develop anxiety

- over diagnosis, treatment, financesThings you can do:

Discuss with your healthcare providerFind a network at local place of worship, family, friends, internetJoin a support groupInvestigate resources to help with finances – just ask!

You are not alone!

Adherence to treatment

“Drugs don’t work if people don’t take them”- C. Everett Koop, MD

Cancer should be a reason to take medicationsCan be intentional and non- intentionalReasons why people don’t take their pills:

“I feel fine”“I forgot”“didn’t refill in time” “Thought I took my medications….”“I cant remember all these pills!”“I don’t need them anymore”.

Adherence with treatment

Important to:Talk to your healthcare providerTalk with family members

RemindersElectronic – alarm clock, watchPaper – calendar, sticky notes

Pill boxesDiary cards

- side effects to report to healthcare provider that may concern you

Conclusion

Patients with cancer are living longer than ever!Newer medications provide hope Improved survival is a welcome benefit but side effects may

prevent the individual from wanting to take their medication

BE AWARE of side effects Report side effects and concerns promptly Pain and suffering are not a necessary part of most people’s

cancer journey and these can be relieved

Reasons why people don’t take t