Chemotherapy Class Participating in Your Care

1. Chemotherapy ClassParticipating in Your Care A New Way of Caring Donna Hafner, RN, MSN, OCN, AOCNS Patient Educator www.VirginiaCancerSpecialists.com

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

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

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

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

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

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

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

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

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

11. Participating in Your Care • What happens if my neutrophils (type of WBC) are low? • Increases your risk of infections • An ANC or GRAN of <1.5 is called Neutropenia • Supportive therapy with growth factor • Stimulates bone marrow to produce more WBCs • Neulasta Injection • Subcutaneous injection usually given the day after chemotherapy treatment • Stays in your body for 14 days • Neupogen Injection • Subcutaneous injection given daily for 7-10 days usually beginning the day following chemotherapy treatment • Bone aching is common side effect from growth factor • Pain reliever can be used to treat unless contraindicated • Antibiotics may be used to help prevent infection • Chemotherapy may need to be delayed until WBCs increase to safe range

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

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

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

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

16. Participating in Your Care • Why are Platelets (Plts) important? • Platelets are cells that help clot blood • Normal Platelet Count • 140,000 – 400,000 • What happens if my Platelets are low? • A decrease in platelets is called Thrombocytopenia • Symptoms of low platelet count • Bruising/small red/purple pin sized dots on skin • Red or pink urine • Black or bloody stool • Bleeding from your gums or nose • Heavy bleeding during your menstrual period • Headaches or changes in vision • DO NOT: • Play contact sports or do activities where you could injure yourself • Use tampons • Use straight edged razor • Supportive therapy for thrombocytopenia • Platelet transfusion if below 20,000 • Chemotherapy may need to be delayed if Platelet count is <100,000

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

18. Participating in Your Care • What is a Nadir? • Period after chemotherapy when your blood counts are at their lowest point • Usually 7-14 days after chemotherapy • Can vary depending on your treatment regimen Chemo starts Next Chemo cycle Blood counts decrease Recovery Period Nadir ~7-14 days

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

42. Participating in Your Care The staff at Virginia Cancer Specialists are here to help you. Thank you for attending! Please complete the class evaluation form.