A special note for caregivers

• • Do not be surprised or upset if your loved one’s tastes change from day to day. There may be days when he or she does not want a favorite food or says it tastes bad now.
  • Keep food within easy reach. This way, your loved one can have a snack when he or she is ready to eat. You might put a snack-pack of applesauce or pudding (along with a spoon) on the bedside table. Or try keeping a bag of cut-up carrots on the refrigerator shelf
  Offer gentle support. This is much more helpful than pushing your loved one to eat. Suggest that he or she drinks plenty of clear and full liquids when he or she has no appetite. For ideas, see the lists of clear liquids and full-liquid foods.
• Talk with your loved one about ways to manage eating problems. Doing this together can help you both feel more in control.

For more information about being a caregiver, see When Someone You Love Is Being Treated for Cancer. You can get this book free from the National Cancer Institute. Call 1-800-4-CANCER (1-800-422-6237) or order online at http://www.cancer.gov/publications.

Using food, vitamins, and other supplements to fight cancer

Many people want to know how they can help their body fight cancer by eating certain foods or taking vitamins or supplements. But, there are no studies that prove that any special diet, food, vitamin, mineral, dietary supplement, herb, or combination of these can slow cancer, cure it, or keep it from coming back. In fact, some of these products can cause other problems by changing how your cancer treatment works. Talk with your doctor, nurse, or dietitian before going on a special diet or taking any supplements. To avoid problems, be sure to follow their advice.
For more information about complementary and alternative therapies, see Thinking About Complementary & Alternative Medicine: A Guide for People With Cancer. You can get this book free from the National Cancer Institute. Call 1-800-4-CANCER (1-800-422-6237) or order online at http://www.cancer.gov/publications.

Taking special care with food to avoid infections

Some cancer treatments can make you more likely to get infections. When this happens, you need to take special care in the way you handle and prepare food. Here are some ways:

• Some cancer treatments can make you more likely to get infections. When this happens, you need to take special care in the way you handle and prepare food. Here are some ways;
• Keep hot foods hot and cold foods cold. Put leftovers in the refrigerator as soon as you are done eating.
• Scrub all raw fruits and vegetables before you eat them. Do not eat foods (like raspberries) that cannot be washed well. You should scrub fruits and vegetables that have rough surfaces, such as melons, before you cut them..
• Wash your hands, knives, and counter tops before and after you prepare food. This is most important when preparing raw meat, chicken, turkey, and fish.
• Use one cutting board for meat and one for fruits and vegetables.
• Thaw meat, chicken, turkey, and fish in the refrigerator or defrost them in the microwave. Do not leave them sitting out.
• Cook meat, chicken, turkey, and eggs thoroughly. Meats should not have any pink inside. Eggs should be hard, not runny.
• Do not eat raw fish or shellfish, such as sushi and uncooked oysters.
• Make sure that all of your juices, milk products, and honey are pasteurized.
• Do not use foods or drinks that are past their freshness date.
• Do not buy foods from bulk bins.
• Do not eat at buffets, salad bars, or self-service restaurants.
• Do not eat foods that show signs of mold. This includes moldy cheeses such as bleu cheese and Roquefort.

For more information about infection and cancer treatment, see Chemotherapy and You: Support for People With Cancer a book from the National Cancer Institute. You can get it free by calling 1-800-4-CANCER (1-800-422-6237) or online at http://www.cancer.gov/publications.

Ways to get the most from foods and drinks

• During treatment, you may have good days and bad days when it comes to food. Here are some ways to manage:
• Eat plenty of protein and calories when you can. This helps you keep up your strength and helps rebuild tissues harmed by cancer treatment.
• Eat when you have the biggest appetite. For many people, this is in the morning. You might want to eat a bigger meal early in the day and drink liquid meal replacements later on.
• Eat those foods that you can, even if it is only one or two items. Stick with these foods until you are able to eat more. You might also drink liquid meal replacements for extra calories and protein.
• Do not worry if you cannot eat at all some days. Spend this time finding other ways to feel better, and start eating when you can. Tell your doctor if you cannot eat for more than 2 days.
• Drink plenty of liquids. It is even more important to get plenty to drink on days when you cannot eat. Drinking a lot helps your body get the liquid it needs. Most adults should drink 8 to 12 cups of liquid a day. You may find this easier to do if you keep a water bottle nearby. See the list of clear liquids for other ideas.

Talk with your doctor, nurse, or dietitian about foods to eat

Talk with your doctor or nurse if you are not sure what to eat during cancer treatment. Ask him or her to refer you to a dietitian. A dietitian is the best person to talk with about your diet. He or she can help choose foods and drinks that are best for you during treatment and after. Make a list of questions for your meeting with the dietitian. Ask about your favorite foods and recipes and if you can eat them during cancer treatment. You might want to find out how other patients manage their eating problems. You can also bring this book and ask the dietitian to mark sections that are right for you.
If you are already on a special diet for diabetes, kidney or heart disease, or other health problem, it is even more important to speak with a doctor and dietitian. Your doctor and dietitian can advise you about how to follow your special diet while coping with eating problems caused by cancer treatment.
For more information on how to find a dietitian, contact the American Dietetic Association. See “Ways to Learn More” for ways to reach them.

Not everyone has eating problems during cancer treatment

There is no way to know if you will have eating problems and, if so, how bad they will be. You may have just a few problems or none at all. In part, this depends on the type of cancer you have, where it is in your body, what kind of treatment you have, how long treatment lasts, and the doses of treatment you receive.
During treatment, there are many helpful medicines and other ways to manage eating problems. Once treatment ends, many eating problems go away. Your doctor, nurse, or dietitian can tell you more about the types of eating problems you might expect and ways to manage them. If you start to have eating problems, tell your doctor or nurse right away.

Ways you can get ready to eat well

• Fill the refrigerator, cupboard, and freezer with healthy foods. Make sure to include items you can eat even when you feel sick.
• Stock up on foods that need little or no cooking, such as frozen dinners and ready-to-eat cooked foods.
• Cook some foods ahead of time and freeze in meal-sized portions.
• Ask friends or family to help you shop and cook during treatment. Maybe a friend can set up a schedule of the tasks that need to be done and the people who will do them.
• Talk with your doctor, nurse, or dietitian about what to expect. See the lists of foods and drinks that can help with many types of eating problems

Things to do and think about before you start cancer treatment

• Until treatment starts you will not know what, if any, side effects or eating problems you may have. If you do have problems, they may be mild. Many side effects can be controlled. Many problems go away when cancer treatment ends.
• Think of your cancer treatment as a time to get well and focus just on yourself.
• Eat a healthy diet before treatment starts. This helps you stay strong during treatment and lowers your risk of infection.
• Go to the dentist. It is important to have a healthy mouth before you start cancer treatment.
• Ask your doctor, nurse, or dietitian about medicine that can help with eating problems.
• Discuss your fears and worries with your doctor, nurse, or social worker. He or she can discuss ways to manage and cope with these feelings.
• Learn about your cancer and its treatment. Many people feel better when they know what to expect.

People with cancer have different diet needs, Eating Well, and Eating Problems

People with cancer often need to follow diets that are different from what they think of as healthy. For most people, a healthy diet includes:

• Lots of fruits and vegetables, and whole grain breads and cereals
• Modest amounts of meat and milk products
• Small amounts of fat, sugar, alcohol, and salt

When you have cancer, though, you need to eat to keep up your strength to deal with the side effects of treatment. When you are healthy, eating enough food is often not a problem. But when you are dealing with cancer and treatment, this can be a real challenge.
When you have cancer, you may need extra protein and calories. At times, your diet may need to include extra milk, cheese, and eggs. If you have trouble chewing and swallowing, you may need to add sauces and gravies. Sometimes, you may need to eat low-fiber foods instead of those with high fiber. Your dietitian can help you with any diet changes you may need to make.

Nausea and Vomiting

Nausea is feeling sick to your stomach. Vomiting means throwing up. Both can be a problem for cancer patients. Untreated nausea and vomiting can make you feel very tired. They can also make it hard to get treatments or to care for yourself. There are many drugs to help you control nausea and vomiting. Ask your doctor which medicines might work best for you.
You also may want to make these changes to your diet:

• Eat small amounts of food five to six times a day.
• Avoid foods that are sweet, fatty, salty, spicy, or have strong smells. These may make nausea and vomiting worse.
• Have as much liquid as possible. You'll want to keep your body from getting too dry (dehydrated). Broth, ice cream, water, juices, herb teas, and watermelon are good choices.

Fatigue

Fatigue is more than feeling tired. Fatigue is exhaustion - not being able to do even the small things you used to do. A number of things can cause fatigue. Besides cancer treatment, they include anxiety, stress, and changes in your diet or sleeping patterns. If you are having some of these problems, you might want to:

• Tell your doctor or nurse at your next visit. Ask about medicines that can help with fatigue.
• Eat a well-balanced diet
• Plan your days and do only what is important to you
• Take short breaks every day to rest and relax
• Take naps
• Ask others for help.

Other Ways To Treat Pain

Cancer pain is usually treated with medicine and other therapies. But there are also some nondrug treatments. They are types of complementary and alternative medicine (CAM). Many people have found the methods listed below helpful. But talk with your health care team before trying any of them. Make sure they are safe and won't interfere with your cancer treatment.

• Acupuncture is a form of Chinese medicine that stimulates certain points on the body using small needles. It may help treat nausea and control pain. Before using acupuncture, ask your health care team if it is safe for your type of cancer.
• Imagery is imagining scenes, pictures, or experiences to feel calmer or perhaps to help the body to heal.
• Relaxation techniques include deep breathing and exercises to relax your muscles.
• Hypnosis is a state of relaxed and focused attention. One focuses on a certain feeling, idea, or suggestion. 
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• Biofeedback is the use of a special machine to help the patient learn how to control certain body functions. These are things that we are normally not aware of (such as heart rate).
• Massage therapy brings relaxation and a sense of well-being by the gentle rubbing of different body parts or muscles. Before you try this, you need to check with your doctor. Massage is not recommended for some kinds of cancer.

These methods may also help manage stress. Again, talk to your health care team before using anything new, no matter how safe it may seem. Ask your health care team for more information about where to get these treatments. To learn more, see the NCI booklet Thinking About Complementary and Alternative Medicine.

Controlling Pain: What To Tell Your Doctor

When describing pain to your doctor, give as much detail as you can. Your doctor may want to know:

• Where exactly is your pain? Does it move from one spot to another?
• How does the pain feel - dull, sharp, burning?
• How often do you have pain?
• How long does it last?
• Does it occur at a certain time of day - morning, afternoon, night?
• What makes the pain better? What makes it worse?
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• People with cancer often need strong medicine to help control their pain. Don't be afraid to ask for pain medicine or for larger doses if you need them. And the drugs will help you stay as comfortable as possible. People with cancer hardly ever get addicted to these drugs. Sadly, fears of addiction sometimes prevent people from taking medicine for pain. The same fears also prompt family members to encourage loved ones to "hold off" between doses. But people in pain get the most relief when they take their medicines and treatments on a regular schedule.

Pain Control

Having cancer doesn't always mean that you'll have pain. But if you do, you shouldn't accept pain as normal. Your doctor can control pain with medicines and other treatments. Managing your pain helps you sleep and eat better. It makes it easier to enjoy your family and friends, and to focus on the things you enjoy.
Have regular talks with your health care team about your pain. Let them know what kind of pain it is, where it is, and how bad it is. These talks are important because pain can change throughout your illness. And your pain may show where cancer has returned after remission. Many hospitals have doctors who are experts in treating pain. Tell your doctor if you would like to talk to a pain specialist.
Your medicine, and how you take it, will depend on the type of pain and its cause. For example, for constant pain you may need a steady dose of medicine over a long period of time. You might use a patch placed on the skin or a slow-release pill.
You may want to keep a pain diary to help you explain your pain to your doctor.Your doctor may also ask you some questions about how your pain affects your daily routine. Having your pain managed means that you can focus on living your life and not be distracted by pain.

Comfort Care to Help

You have a right to comfort care both during and after treatment. This kind of care is often called palliative (PAL-ee-yuh-tiv) care. It includes treating or preventing cancer symptoms and the side effects caused by treatment. Comfort care can also mean getting help with emotional and spiritual problems during and after cancer treatment.
People once thought of palliative care as a way to comfort those dying of cancer. Doctors now offer this care to all cancer patients, beginning when the cancer is diagnosed. You should receive palliative care through treatment, survival, and advanced disease. Your oncologist may be able to help you. But a palliative care specialist may be the best person to treat some problems. Ask your doctor or nurse if there is a specialist you can go to.

"For me personally, the challenge is not to let the treatments get the best of me. I make sure if I have any new aches or pains I tell my doctor right away. He's great about working with me to handle these things." - Edna

Legal Papers At-A-Glance

Advance directives

• A living will lets people know what kind of medical care you want if you are unable to speak for yourself.
• A durable power of attorney for health care names a person to make medical decisions for you if you can't make them yourself. This person is called a health care proxy.

Other legal papers that are not part of the advance directives

• A will tells how you want to divide your money and property among your heirs. (Heirs are usually the family members who survive you. You may also name other people as heirs in your will.)
• Power of attorney appoints a person to make financial decisions for you when you can't make them yourself.

Note: You do not always need a lawyer present to fill out these papers. But you may need a notary public. Each state has its own laws about advance directives. Check with your lawyer or social worker about the laws in your state.

Making Your Wishes Known

When cancer returns, the treatment goals may change, or they may be the same as they were for your first cancer. But for many people, it's the second cancer diagnosis that finally prompts them to make their wishes known. Although it can be tough to think about, and maybe even tougher to talk about, having recurrent cancer may prompt you to make certain decisions about what you want done for you if you are unable to speak for yourself.
Everyone should make a will and talk about end-of-life choices with loved ones. This is one of the most important things you can do. Also, think about giving someone you trust some rights to make medical decisions for you. You give these rights through legal documents called advance directives. These papers tell your loved ones and doctors what to do if you can't tell them yourself. They let you decide ahead of time how you want to be treated. These papers may include a living will and a durable power of attorney for health care.
Setting up an advance directive is not the same as giving up. Making such decisions at this time keeps you in control. You are making your wishes known for all to follow. This can help you worry less about the future and live each day to the fullest.
It's hard to talk about these issues. But it often comforts family members to know what you want. And it saves them from having to bring up the subject themselves. You may also gain peace of mind. You are making these hard choices for yourself instead of leaving them to your loved ones.
Make copies of your advance directives. Give them to your family members, your health care team, and your hospital medical records department. That way, everyone will know your decisions.

Questions to Ask Your Doctor or Nurse About Treatment Choices

Decide on the most important things you need to ask your doctor or nurse. Some ideas:

• What are my treatment choices?
• Which do you suggest for me?
• How is this treatment the same as or different from my last treatment?
• How successful is the treatment you recommend? Why is it best for me?
• Will I still be able to do things I enjoy with the treatment? Without the treatment?
• How long will I be on this treatment?
• Will I have side effects? If so, how long will they last?
• How can I manage the side effects?
• Will I have to stay in the hospital?
• Is a clinical trial available to me?
• Will I have to pay any costs in a clinical trial?
• If the treatment doesn't work, then what will I do?

Clinical Trials

Treatment clinical trials are research studies that try to find better ways to treat cancer. Every day, cancer researchers learn more about treatment options from clinical trials.
Each study has rules about who can take part. These rules include the person's age and type of cancer. They also cover earlier treatments and where the cancer has returned.
Clinical trials have both benefits and risks. Your doctor should tell you about them before you make any decisions about taking part.
There are different phases of clinical trials. They include:

• Phase I trials test what dose of a treatment is safe and how it should be given.
• Phase II trials discover how cancer responds to a new drug or treatment.
• Phase III trials compare an accepted cancer treatment (standard treatment) with a new treatment that researchers hope is better.

Taking part in a clinical trial could help you and others who get cancer in the future. But insurance and managed care plans do not always cover the costs. What they cover varies by plan and by study. If you want to learn more about clinical trials, talk with your health care team.
For more information about clinical trials, see NCI's brochure Taking Part in Cancer Treatment Research Studies.

Should I Get A Second Opinion?

Some patients worry that doctors will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for them.
If you get a second opinion, the doctor may agree with your first doctor's treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options.

Treatment Choices

There are many treatment choices for recurrent cancer. Your treatment will depend partly on the type of cancer and the treatment you had before. It will also depend on where the cancer has recurred. For example:

• A local recurrence may be best treated by surgery or radiation therapy. This means that the doctor removes the tumor or destroys it with radiation.
• A distant recurrence may need chemotherapy, biological therapy, or radiation therapy. (For more information see the NCI booklets Radiation Therapy and You and Chemotherapy and You.)

It's important to ask your doctor questions about all your treatment choices. You may want to get a second opinion as well. You may also want to ask whether a clinical trial is an option for you.

Other Tips for Talking With Your Health Care Team

• Speak openly about your needs, questions, and concerns. Don't be embarrassed to ask your doctor to repeat or explain something.
• Keep a file or notebook of all the papers and test results that your doctor has given you. Take this file to your visits. Also keep records or a diary of all your visits. List the drugs and tests you have taken. Then you can refer to your records when you need to. Many patients say this is helpful, especially when you meet with a new doctor for the first time.
• Write down your questions before you see your doctors so you will remember them. 
• Ask a family member or friend to go to the doctor's office with you. They can help you ask questions to get a clear sense of what to expect. This can be an emotional time. You may have trouble focusing on what the doctor says. It may be easier for someone else to take notes. Then you can review them later.
• Ask your doctor if it's okay to tape-record your talks.
• Tell your doctor if you want to get dressed before talking about your results. Wearing a gown or robe is distracting for some patients. They find it harder to focus on what the doctor is saying
•  

"You need a notebook because you go to the doctors and they're telling you things, and you're so scared that you don't really listen. Then you get home, and you can't even remember what they said."- Jake

Talking With Your Health Care Team

Many people have a treatment team of health providers who work together to help them. This team may include doctors, nurses, oncology social workers, dietitians, or other specialists. Some people don't like to ask about treatment choices or side effects. They think that doctors don't like being questioned. But this is not true. Most doctors want their patients to be involved in their own care. They want patients to discuss concerns with them.
Here are a few topics you may want to discuss with your health care team:

• Pain or Other Symptoms. Be honest and open about how you feel. Tell your doctors if you have pain and where. Tell them what you expect in the way of pain relief. 
• Communication. Some people want to know details about their care. Others prefer to know as little as possible. Some people with cancer want their family members to make most of their decisions. What would you prefer? Decide what you want to know, how much you want to know, and when you've heard enough. Choose what is most comfortable for you. Then tell your doctor and family members. Ask that they follow through with your wishes.
• Family Wishes. Some family members may have trouble dealing with cancer. They don't want to know how far the disease has advanced. Find out from your family members how much they want to know. And be sure to tell your doctors and nurses. Do this as soon as possible. It will help avoid conflicts or distress among your loved ones.
•  

"I always ask lots of questions because I want to be ready just in case something happens. I really do believe that everyone taking care of me has my best interests at heart. But I worry that if I don't ask about everything, they may forget to give me the answers." - Bonita

Where Cancer Can Return

Doctors define recurrent cancers by where they develop. The different types of recurrence are:

• Local recurrence. This means that the cancer is in the same place as the original cancer or is very close to it.
• Regional recurrence. This is when tumors grow in lymph nodes or tissues near the place of the original cancer.
• Distant recurrence. In these cases, the cancer has spread (metastasized) to organs or tissues far from the place of the original cancer.

Local cancer may be easier to treat than regional or distant cancer. But this can be different for each patient. Talk with your doctor about your options

Why and Where Cancer Returns

"I was floored. I thought all the cancer was gone. I was just getting back to a normal life. I was even more surprised that it came back in a different place. But I didn't care where it was. I just wanted it to go away." - Ronald 

 

When cancer comes back, doctors call it a recurrence (or recurrent cancer). Some things you should know are:

• A recurrent cancer starts with cancer cells that the first treatment didn't fully remove or destroy. Some may have been too small to be seen in follow-up. This doesn't mean that the treatment you received was wrong. And it doesn't mean that you did anything wrong, either. It just means that a small number of cancer cells survived the treatment. These cells grew over time into tumors or cancer that your doctor can now detect.
• When cancer comes back, it doesn't always show up in the same part of the body. For example, if you had colon cancer, it may come back in your liver. But the cancer is still called colon cancer. When the original cancer spreads to a new place, it is called a metastasis (meh-TAS-tuh-sis).
• It is possible to develop a completely new cancer that has nothing to do with your original cancer. But this doesn't happen very often. Recurrences are more common.

When Cancer Returns

"One minute everything was fine, and then my doctor dropped the bomb that my cancer had come back. In 5 short minutes, my life had changed again." - Dorothy

Maybe in the back of your mind, you feared that your cancer might return. Now you might be thinking, "How can this be happening to me again? Haven't I been through enough?"
You may be feeling shocked, angry, sad, or scared. Many people have these feelings. But you have something now that you didn't have before - experience. You've lived through cancer once. You know a lot about what to expect and hope for.
Also remember that treatments may have improved since you had your first cancer. New drugs or methods may help with your treatment or in managing side effects. In fact, cancer is now often thought of as a chronic disease, one which people manage for many years.

"When I found out I had cancer again, I just felt numb. It was hard for me to accept the news at first. After a few weeks, though, I started to really look at all my options and things I could do for myself. By doing this, it gave me back some control."

How can I cope with my feelings during chemotherapy?

• Relax. Find some quiet time and think of yourself in a favorite place. Breathe slowly or listen to soothing music. This may help you feel calmer and less stressed.
• Exercise. Many people find that light exercise helps them feel better. There are many ways for you to exercise, such as walking, riding a bike, and doing yoga. Talk with your doctor or nurse about ways you can exercise.
• Talk with others. Talk about your feelings with someone you trust. Choose someone who can focus on you, such as a close friend, family member, chaplain, nurse, or social worker. You may also find it helpful to talk with someone else who is getting chemotherapy.
• Join a support group. Cancer support groups provide support for people with cancer. These groups allow you to meet others with the same problems. You will have a chance to talk about your feelings and listen to other people talk about theirs. You can find out how others cope with cancer, chemotherapy, and side effects. Your doctor, nurse, or social worker may know about support groups near where you live. Some support groups also meet online (over the Internet), which can be helpful if you cannot travel.

Talk to your doctor or nurse about things that worry or upset you. You may want to ask about seeing a counselor. Your doctor may also suggest that you take medication if you find it very hard to cope with your feelings.

Your Feelings During Chemotherapy

At some point during chemotherapy, you may feel:

• Anxious
• Depressed
• Afraid
• Angry
• Frustrated
• Helpless
• Lonely

It is normal to have a wide range of feelings while going through chemotherapy. After all, living with cancer and getting treatment can be stressful. You may also feel fatigue, which can make it harder to cope with your feeling

Tips for Meeting With Your Doctor or Nurse

• Make a list of your questions before each appointment. Some people keep a "running list" and write down new questions as they think of them. Make sure to have space on this list to write down the answers from your doctor or nurse.
• Bring a family member or trusted friend to your medical visits. This person can help you understand what the doctor or nurse says and talk with you about it after the visit is over.
• Ask all your questions. There is no such thing as a stupid question. If you do not understand an answer, keep asking until you do.
• Take notes. You can write them down or use a tape recorder. Later, you can review your notes and remember what was said.
• Ask for printed information about your type of cancer and chemotherapy.
• Let your doctor or nurse know how much information you want to know, when you want to learn it, and when you have learned enough. Some people want to learn everything they can about cancer and its treatment. Others only want a little information. The choice is yours.
• Find out how to contact your doctor or nurse in an emergency. This includes who to call and where to go.

What are clinical trials and are they an option for me?

Cancer clinical trials (also called cancer treatment studies or research studies) test new treatments for people with cancer. These can be studies of new types of chemotherapy, other types of treatment, or new ways to combine treatments. The goal of all these clinical trials is to find better ways to help people with cancer.
Your doctor or nurse may suggest you take part in a clinical trial. You can also suggest the idea. Before you agree to be in a clinical trial, learn about:

• Benefits. All clinical trials offer quality cancer care. Ask how this clinical trial could help you or others. For instance, you may be one of the first people to get a new treatment or drug.
• Risks. New treatments are not always better or even as good as standard treatments. And even if this new treatment is good, it may not work well for you.
• Payment. Your insurance company may or may not pay for treatment that is part of a clinical trial. Before you agree to be in a trial, check with your insurance company to make sure it will pay for this treatment.

Contact the NCI's Cancer Information Service if you are interested in learning more about clinical trials. See Ways To Learn More for ways to contact them.

How can I best work with my insurance plan?

• Read your insurance policy before treatment starts to find out what your plan will and will not pay for.
• Keep records of all your treatment costs and insurance claims.
• Send your insurance company all the paperwork it asks for. This may include receipts from doctors' visits, prescriptions, and lab work. Be sure to also keep copies for your own records.
• As needed, ask for help with the insurance paperwork. You can ask a friend, family member, social worker, or local group such as a senior center.
• If your insurance does not pay for something you think it should, find out why the plan refused to pay. Then talk with your doctor or nurse about what to do next. He or she may suggest ways to appeal the decision or other actions to take.

Does my health insurance pay for chemotherapy?

Talk with your health insurance plan about what costs it will pay for. Questions to ask include:

• What will my insurance pay for?
• Do I or does the doctor's office need to call my insurance company before each treatment for it to be paid for?
• What do I have to pay for?
• Can I see any doctor I want or do I need to choose from a list of preferred providers?
• Do I need a written referral to see a specialist?
• Is there a co-pay (money I have to pay) each time I have an appointment?
• Is there a deductible (certain amount I need to pay) before my insurance pays?
• Where should I get my prescription drugs?
• Does my insurance pay for all my tests and treatments, whether I am an inpatient or outpatient?

How much does chemotherapy cost?

It is hard to say how much chemotherapy will cost. It depends on:

• The types and doses of chemotherapy used
• How long and how often chemotherapy is given
• Whether you get chemotherapy at home, in a clinic or office, or during a hospital stay
• The part of the country where you live
• Costs are covered under Medicare and Medicaid, of course prior notification and
• admission is required

How will I know if my chemotherapy is working?

Your doctor will give you physical exams and medical tests (such as blood tests and x-rays). He or she will also ask you how you feel.
You cannot tell if chemotherapy is working based on its side effects. Some people think that severe side effects mean that chemotherapy is working well. Or that no side effects mean that chemotherapy is not working. The truth is that side effects have nothing to do with how well chemotherapy is fighting your cancer.

Can I take vitamins, minerals, dietary supplements, or herbs while I get chemotherapy?

Some of these products can change how chemotherapy works. For this reason, it is important to tell your doctor or nurse about all the vitamins, minerals, dietary supplements, and herbs that you take before you start chemotherapy. During chemotherapy, talk with your doctor before you take any of these products.
Combinations of various herbs and minerals can actually block the effect of the Chemo. Large doses of Beta-blockers can hinder the way chemo is being absorbed by your cells. Types of Chemo which attaches to protein molecules that are to be absorbed by the cancer cell are blocked by high levels of the anti-oxidants.
This is why, it is extremely important to discuss with your doctor all consumed supplemental products before and during chemo therapy.  

Can I take over-the-counter and prescription drugs while I get chemotherapy?

This all depends on the type of chemotherapy you get and the other types of drugs you plan to take. Take only drugs that are approved by your doctor or nurse. Tell your doctor or nurse about all the over-the-counter and prescription drugs you take, including laxatives, allergy medicines, cold medicines, pain relievers, aspirin, and ibuprofen.
One way to let your doctor or nurse know about these drugs is by bringing in all your pill bottles. Your doctor or nurse needs to know:

• The name of each drug
• The reason you take it
• How much you take
• How often you take it

Can I work during chemotherapy?

Many people can work during chemotherapy, as long as they match their schedule to how they feel. Whether or not you can work may depend on what kind of work you do. If your job allows, you may want to see if you can work part-time or work from home on days you do not feel well.
Many employers are required by law to change your work schedule to meet your needs during cancer treatment. Talk with your employer about ways to adjust your work during chemotherapy. You can learn more about these laws by talking with a social worker

How will I feel during chemotherapy?

Chemotherapy affects people in different ways. How you feel depends on how healthy you are before treatment, your type of cancer, how advanced it is, the kind of chemotherapy you are getting, and the dose. Doctors and nurses cannot know for certain how you will feel during chemotherapy.
Some people do not feel well right after chemotherapy. The most common side effect is fatigue, feeling exhausted and worn out. You can prepare for fatigue by:

• Asking someone to drive you to and from chemotherapy
• Planning time to rest on the day of and day after chemotherapy
• Getting help with meals and childcare the day of and at least 1 day after chemotherapy

There are many ways you can help manage chemotherapy side effects. For more information, see the Side Effects At-A-Glance section

Things to know about getting chemotherapy through an IV

Chemotherapy is often given through a thin needle that is placed in a vein on your hand or lower arm. Your nurse will put the needle in at the start of each treatment and remove it when treatment is over. Let your doctor or nurse know right away if you feel pain or burning while you are getting IV chemotherapy.
IV chemotherapy is often given through catheters or ports, sometimes with the help of a pump.

• Catheters. A catheter is a soft, thin tube. A surgeon places one end of the catheter in a large vein, often in your chest area. The other end of the catheter stays outside your body. Most catheters stay in place until all your chemotherapy treatments are done. Catheters can also be used for drugs other than chemotherapy and to draw blood. Be sure to watch for signs of infection around your catheter. 
• Ports. A port is a small, round disc made of plastic or metal that is placed under your skin. A catheter connects the port to a large vein, most often in your chest. Your nurse can insert a needle into your port to give you chemotherapy or draw blood. This needle can be left in place for chemotherapy treatments that are given for more than 1 day. Be sure to watch for signs of infection around your port.
• Pumps. Pumps are often attached to catheters or ports. They control how much and how fast chemotherapy goes into a catheter or port. Pumps can be internal or external. External pumps remain outside your body. Most people can carry these pumps with them. Internal pumps are placed under your skin during surgery.

How is chemotherapy given

Chemotherapy may be given in many ways.

• Injection. The chemotherapy is given by a shot in a muscle in your arm, thigh, or hip or right under the skin in the fatty part of your arm, leg, or belly.
• Intra-arterial (IA). The chemotherapy goes directly into the artery that is feeding the cancer.
• Intraperitoneal (IP). The chemotherapy goes directly into the peritoneal cavity (the area that contains organs such as your intestines, stomach, liver, and ovaries).
• Intravenous (IV). The chemotherapy goes directly into a vein.
• Topically. The chemotherapy comes in a cream that you rub onto your skin.
• Orally. The chemotherapy comes in pills, capsules, or liquids that you swallow.

More Questions and Answers About Chemotherapy

How does my doctor decide which chemotherapy drugs to use?

This choice depends on:

• The type of cancer you have. Some types of chemotherapy drugs are used for many types of cancer. Other drugs are used for just one or two types of cancer.
• Whether you have had chemotherapy before
• Whether you have other health problems, such as diabetes or heart disease

Where do I go for chemotherapy?

You may receive chemotherapy during a hospital stay, at home, or in a doctor's office, clinic, or outpatient unit in a hospital (which means you do not have to stay overnight). No matter where you go for chemotherapy, your doctor and nurse will watch for side effects and make any needed drug changes.

How often will I receive chemotherapy?

Treatment schedules for chemotherapy vary widely. How often and how long you get chemotherapy depends on:

• Your type of cancer and how advanced it is
• The goals of treatment (whether chemotherapy is used to cure your cancer, control its growth, or ease the symptoms)
• The type of chemotherapy
• How your body reacts to chemotherapy

You may receive chemotherapy in cycles. A cycle is a period of chemotherapy treatment followed by a period of rest. For instance, you might receive 1 week of chemotherapy followed by 3 weeks of rest. These 4 weeks make up one cycle. The rest period gives your body a chance to build new healthy cells.

Can I miss a dose of chemotherapy?

It is not good to skip a chemotherapy treatment. But sometimes your doctor or nurse may change your chemotherapy schedule. This can be due to side effects you are having. If this happens, your doctor or nurse will explain what to do and when to start treatment again.

Questions and Answers About Chemotherapy

What is chemotherapy?

Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to destroy cancer cells.

How does chemotherapy work?

Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly. But it can also harm healthy cells that divide quickly, such as those that line your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side effects. Often, side effects get better or go away after chemotherapy is over.

What does chemotherapy do?

Depending on your type of cancer and how advanced it is, chemotherapy can:

• Cure cancer - when chemotherapy destroys cancer cells to the point that your doctor can no longer detect them in your body and they will not grow back.
• Control cancer - when chemotherapy keeps cancer from spreading, slows its growth, or destroys cancer cells that have spread to other parts of your body.
• Ease cancer symptoms (also called palliative care) - when chemotherapy shrinks tumors that are causing pain or pressure.

How is chemotherapy used?

Sometimes, chemotherapy is used as the only cancer treatment. But more often, you will get chemotherapy along with surgery, radiation therapy, or biological therapy. Chemotherapy can:

• Make a tumor smaller before surgery or radiation therapy. This is called neo-adjuvant chemotherapy.
• Destroy cancer cells that may remain after surgery or radiation therapy. This is called adjuvant chemotherapy.
• Help radiation therapy and biological therapy work better.
• Destroy cancer cells that have come back (recurrent cancer) or spread to other parts of your body (metastatic cancer).

Human immunodeficiency virus and other Infections

Human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS). Testing each unit of donated blood for HIV began in 1985, and all donated blood is now tested for HIV.

With improved testing for HIV, the number of transfusion-related AIDS cases continues to drop. The risk of HIV transmission from a transfusion is about 1 in 2 million. Along with testing, the risk is reduced by asking donors questions about HIV risk factors and symptoms.

Other infections

Along with the tests noted above, all blood for transfusion is tested for syphilis, as well as HTLV-I and HTLV-II (viruses linked to human T-cell leukemia/lymphoma). Since 2003, donated blood has been tested for the West Nile virus, too. In 2007, blood banks also began testing for Chagas disease (common in South and Central America).

Diseases caused by certain bacteria, viruses, and parasites, such as babesiosis, malaria, Lyme disease, and others can also be spread by blood product transfusions. But because potential donors are screened with questions about their health status and travel, such cases are very rare.

Hepatitis B and C: Most common complication of Blood Transfusions

Viruses that attack the liver cause these forms of hepatitis. Hepatitis is the most common disease transmitted by blood transfusions. A 2009 study on hepatitis B in donated blood suggested that the risk is about 1 in every 800,000 units or less. About 1 blood transfusion in 1.6 million may transmit hepatitis C.

Work continues to be done to reduce the risk of these infections even further. In most cases there are no symptoms, but hepatitis can sometimes lead to liver failure and other problems.

Several steps are routinely taken to reduce the risk of hepatitis from blood transfusion. People who are getting ready to donate blood are asked questions about hepatitis risk factors and symptoms of hepatitis. Donated blood is also tested to find hepatitis B virus, hepatitis C virus, and liver problems that could be signs of other types of hepatitis.

Infections and Bacterial Contaminations

Infections

Blood transfusions can transmit infections caused by bacteria, viruses, and parasites. The chance of getting an infection from blood in the United States is extremely low, but the exact risk for each type of infection varies. Testing units of blood for germs that can cause infection has made the blood supply very safe, but no test is 100% accurate.

Bacterial contamination

Rarely, blood gets contaminated with tiny amounts of skin bacteria during donation. Platelets are the most likely blood component to have this problem. Because platelets must be stored at room temperature, these bacteria can grow quickly. (Other components are refrigerated or frozen.) Patients who get these platelets may develop a serious illness minutes or hours after the transfusion starts.

Blood banks routinely test platelets and destroy units of blood that are likely to cause harm. The tests are still being refined, but today fewer cases of illness are caused by platelets. Also, more hospitals use single donor platelets, which have a lower risk of bacterial contamination than pooled platelets.

Graft-versus-host disease

Graft-versus-host disease (GVHD) occurs when a person with a very weak immune system gets white blood cells in a transfused blood product. The white cells in the transfusion attack the tissues of the patient who got the blood.

This is more likely if the blood comes from a relative or someone who has the same tissue type (this is different from blood type) as the patient. The patient’s immune system doesn’t recognize the white blood cells in the transfused blood as foreign. This allows the white blood cells to survive and attack the patient’s body tissues.

Within a month of the transfusion, the patient may have fever, liver problems, rash, and diarrhea.

To prevent white blood cells from causing GVHD, donated blood can be treated with radiation before transfusion. (Radiation stops white blood cells from working but does not affect red blood cells.) These are called irradiated blood products. They are often used for people with cancer who might have weakened immune systems.

More possible Risks

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a rare, but very serious transfusion reaction. It can happen with any type of transfusion, but those that contain more plasma, such as fresh frozen plasma or platelets, seem more likely to cause it. It often starts within 1 to 2 hours of starting the transfusion, but can happen anytime up to 6 hours after a transfusion. There’s also a delayed TRALI syndrome, which can begin up to 72 hours after the transfusion is given.

The main symptom of TRALI is trouble breathing, which can become life-threatening. If TRALI is suspected during the transfusion, the transfusion should be stopped right away.

Doctors now believe that several factors are involved in this illness, and medicines don’t seem to help. Many of the patients who get TRALI have had recent surgery, trauma, cancer treatment, transfusions, or have an active infection. Most of the time, TRALI goes away within 2 or 3 days if breathing and blood pressure are supported, but even with support it is deadly in 5% to 10% of cases. TRALI is more likely to be fatal if the patient was already very ill before the transfusion. Most often a patient will need oxygen, fluids, and sometimes support with a breathing machine.

Delayed TRALI has a higher risk of death, with one expert finding a death rate as high as 40%. If a patient who has had TRALI needs red blood cells, doctors may try to prevent future problems by removing most of the plasma from the red blood cells using a diluted salt water solution. Researchers are working on other ways to reduce this risk with careful donor selection and testing.

Acute immune hemolytic reaction

An acute hemolytic (he-mo-LIT-ik) reaction is the most serious type of transfusion reaction, but it’s very rare. It happens when donor and patient blood types do not match. The patient’s antibodies attack the transfused red blood cells, causing them to break open (hemolyze) and release harmful substances into the bloodstream.

Patients may have chills, fever, chest and lower back pain, and nausea. The kidneys may be badly damaged, and dialysis may be needed. A hemolytic reaction can be deadly if the transfusion is not stopped as soon as the reaction starts.

Delayed hemolytic reaction

This type of reaction happens when the body slowly attacks antigens (other than ABO antigens) on the transfused blood cells. The blood cells are broken down days or weeks after the transfusion. There are usually no symptoms, but the transfused red blood cells are destroyed and the patient’s red blood cell count falls. In rare cases, the kidneys may be affected, and treatment may be needed.

People don’t usually have this type of reaction unless they have had transfusions in the past. Those who do have this reaction need special blood tests before any more blood can be transfused. Units of blood that do not have the antigen that the body is attacking must be used.

Possible risks of blood transfusions

Although blood transfusions can be life-saving, they are not without risks. Infections were once the main risk, but they have become extremely rare with careful testing and donor screening. Transfusion reactions and other non-infectious problems are now more common.

When you are getting a transfusion of any kind, it’s very important that you let your nurse know right away if you notice any changes in how you feel, such as itching, shivering, headache, chest or back pain, throat tightness, nausea, dizziness, trouble breathing, or other problems. You should report any that happen in the next few days, too.

Transfusion reactions

Blood transfusions sometimes cause transfusion reactions. There are several types of reactions and some are worse than others. Some reactions happen as soon as the transfusion is started, while others take several days or even longer to develop.

Many precautions are taken before a transfusion is started to keep reactions from happening. The blood type of the unit is checked many times, and the unit is cross-matched to be sure that it matches the blood type of the person who will get it. After that, both a nurse and blood bank lab technician look at the information about the patient and the information on the unit of blood (or blood component) before it’s released. The information is double-checked once more in the patient’s presence before the transfusion is started.

Allergic reaction

This is the most common reaction. It happens during the transfusion when the body reacts to plasma proteins or other substances in the donated blood. Usually the only symptoms are hives and itching, which can be treated with antihistamines like diphenhydramine (Benadryl). In rare cases these reactions can be more serious.

Febrile reaction

The person gets a sudden fever during or within 24 hours of the transfusion. Headache, nausea, chills, or a general feeling of discomfort may come with the fever. Acetaminophen (Tylenol) may help these symptoms.

These reactions are often the body’s response to white blood cells in the donated blood. They are more common in people who have had transfusions before and in women who have been pregnant several times. Other types of reaction can also cause fever, and further testing may be needed to be sure that the reaction is only febrile.

Patients who have had febrile reactions or who are at risk for them are usually given blood products that are leukoreduced (loo-ko-re-DUCED). This means that the white blood cells have been removed by filters or other means.

Skin and Nail Changes due to Chemo

Some types of chemotherapy can damage the fast-growing cells in your skin and nails. While these changes may be painful and annoying, most are minor and do not require treatment. Many of them will get better once you have finished chemotherapy. However, major skin changes need to be treated right away because they can cause life-long damage.
Minor skin changes may include:

• Itching, dryness, redness, rashes, and peeling
• Darker veins. Your veins may look darker when you get chemotherapy through an IV.
• Sensitivity to the sun (when you burn very quickly). This can happen even to people who have very dark skin color.
• Nail problems. This is when your nails become dark, turn yellow, or become brittle and cracked. Sometimes your nails will loosen and fall off, but new nails will grow back in.

Major skin changes can be caused by:

• Radiation recall. Some chemotherapy causes skin in the area where you had radiation therapy to turn red (ranging from very light to bright red). Your skin may blister, peel, or be very painful.
• Chemotherapy leaking from your IV. You need to let your doctor or nurse know right away if you have burning or pain when you get IV chemotherapy.
• Allergic reactions to chemotherapy. Some skin changes mean that you are allergic to the chemotherapy. Let your doctor or nurse know right away if you have sudden and severe itching, rashes, or hives, along with wheezing or other trouble breathing.
• Itching, dryness, redness, rashes, and peeling
• Apply cornstarch, as you would dusting powder.
• Take quick showers or sponge baths instead of long, hot baths.
• Pat (do not rub) yourself dry after bathing.
• Wash with a mild, moisturizing soap.
• Put on cream or lotion while your skin is still damp after washing. Tell your doctor or nurse if this does not help.
• Do not use perfume, cologne, or aftershave lotion that has alcohol.
• Take a colloidal oatmeal bath (special powder you add to bath water) when your whole body itches
• Keep your face clean and dry.
• Ask your doctor or nurse if you can use medicated creams or soaps and which ones to use.

Sensitivity to the sun

• Avoid direct sunlight. This means not being in the sun from 10 a.m. until 4 p.m. It is the time when the sun is strongest.
• Use sunscreen lotion with an SPF (skin protection factor) of 15 or higher. Or use ointments that block the sun's rays, such as those with zinc oxide.
• Keep your lips moist with a lip balm that has an SPF of 15 or higher.
• Wear light-colored pants, long-sleeve cotton shirts, and hats with wide brims.
• Do not use tanning beds
•  
• Nail problems
  • Wear gloves when washing dishes, working in the garden, or cleaning the house.
  • Use products to make your nails stronger. (Stop using these products if they hurt your nails or skin.)
  • Let your doctor or nurse know if your cuticles are red and painful.
  • Protect the area of your skin that received radiation therapy from the sun, and do not use tanning beds.
  • Place a cool, wet cloth where your skin hurts.
  • Wear clothes that are made of cotton or other soft fabrics. This includes your underwear (bras, underpants, and t-shirts).
  • Let your doctor or nurse know if you think you have radiation recall

Managing Sexual Changes

• For Women: Talk with your doctor or nurse about:
  • Sex. Ask your doctor or nurse if it is okay for you 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 not get pregnant while having 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 doctor or nurse about birth control and ways to keep from getting pregnant.
  • Medications. Talk with your doctor, nurse, or pharmacist about medications that help with sexual problems. These include products to relieve vaginal dryness or a vaginal cream or suppository to reduce the chance of infection.
  • Wear cotton underwear (cotton underpants and pantyhose with cotton linings).
  • Do not wear tight pants or shorts.
  • Use a water-based vaginal lubricant (such as K-Y Jelly® or Astroglide®) when you have sex.
  • If sex is still painful because of dryness, ask your doctor or nurse about medications to help restore moisture in your vagina.
  • Cope with hot flashes by:
    • Dressing in layers, with an extra sweater or jacket that you can take off.
    • Being active. This includes walking, riding a bike, or other types of exercise.
    • Reducing stress. Try yoga, meditation, or other ways to relax.
  • For Men: Talk with your doctor or nurse about:
    • Sex. Ask your doctor or nurse if it is okay for you to have sex during chemotherapy. Most men can have sex, but it is a good idea to ask. Also, ask if you should use a condom when you have sex, since traces of chemotherapy may be in your semen..
    • Birth control. It is very important that your spouse or partner not get pregnant while you are getting chemotherapy. Chemotherapy can damage your sperm and cause birth defects.
    •  For Women and Men:
    • Be open and honest with your spouse or partner. Talk about your feelings and concerns.
    • Explore new ways to show love. You and your spouse or partner may want to show your love for each other in new ways while you go through chemotherapy. 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.
    • Talk with a doctor, nurse, social worker, or counselor. If you and your spouse or partner are concerned about sexual problems, you may want to talk with someone who can help. This can be a psychiatrist, psychologist, social worker, marriage counselor, sex therapist, or clergy member.