Chemotherapy is the use of drugs to treat cancer. Unlike normal cells, which divide and die in a regulated cycle, cancer cells multiply without control. Chemotherapy works to stop the division and growth of these cells.

• Understanding Chemotherapy
• The Day Before Treatment
• The Day of Treatment
• The Treatment Process
• After Treatment
• Side Effects
• Impact on Your Immune System
• What to Do if You Experience a Medical Problem
• Medication Refills
• Summary

Understanding Chemotherapy

Chemotherapy comes in several forms. It may be injected into a vein, taken as a pill or given as a shot into the muscle or under the skin. You may receive one chemotherapy drug or a combination of several drugs. Chemotherapy may be used alone, in combination with "immunotherapy" techniques (which involve the body’s own immune system in fighting the disease) or in addition to surgery and/or radiation therapy. Chemotherapy may be given daily, weekly or monthly, and can last anywhere from a few minutes to several hours. The type of therapy you receive depends on your cancer diagnosis, and will be discussed with you in detail by your physician before you begin treatment.

We know that the word "chemotherapy" is frightening. This time may feel overwhelming to you and to your family. At PAMF, we make it a priority to do everything possible to make the treatment process as easy as possible.

Our physicians and staff members are here to help guide and support you through your treatment program. Whether this is your first time receiving chemotherapy or you have been through treatment previously, you likely have many questions and concerns. We will speak to you in detail about your individual chemotherapy program; give you booklets, handouts and other written information to read; and make sure you have a schedule of your specific chemotherapy course. (You may also find it helpful to carry a small calendar to keep track of appointment dates and other information.)

We want to ensure that you have all the information you need to ease your chemotherapy treatment. If you have any questions, please do not hesitate to ask.
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The Day Before Treatment

Before each chemotherapy treatment (except for your very first treatment), you will need to have your blood drawn. This may be done a full 24 hours before your treatment appointment if you like. In PAMF’s electronic medical record system, we will mark your blood work as a “standing order,” meaning that you will not need an appointment for this service. You may also use laboratories at any PAMF facility. You do not need to fast in advance of the blood draw.

In addition, observe the following guidelines the day before treatments:

• If you have been instructed to take any "pre-medications" before treatment, please start those medications as scheduled.
  
• Stay hydrated to help your veins "puff up." Drink six to eight 8-oz. glasses of fluid. Avoid alcohol and caffeine, which tend to cause dehydration.
  
• If you have been asked to arrange a ride to or from your treatment, please make sure you have done so. (In most chemotherapy programs, you will be able to drive yourself.)

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The Day of Treatment

The Department of Medical Oncology gives treatments throughout the day. You will need to arrive earlier in the day for longer treatments. We will do our best to accommodate your scheduling requests, although we may not always be able to provide your first choice. In addition, we will do our best to deliver treatment as quickly as possible; however, our first priority is to ensure that chemotherapy is given safely, and we ask for your patience and understanding if your treatment takes longer than predicted.

You may eat and drink before your treatment, and in fact, it is best to have something in your stomach before receiving chemotherapy drugs. Eat light, starchy foods and avoid foods that are fatty, spicy or greasy (see the enclosed Dietary Guidelines handout). Keep hydrated as well; you will be able to use the restroom during treatment.

Dress in layers in case the temperature in the chemotherapy suite is not comfortable for you. Heat makes the veins dilate and become "fatter," allowing chemotherapy to be more easily administered, and we have blankets if you are too cold. Try to wear clothes without tight sleeves so that we have easy access to your forearm, where the intravenous line will be placed.

If you will be at the Clinic for several hours, please bring any medications that you are scheduled to take during that time. If you would like to eat, we have a supply of snacks, teas, broth, cookies and juice. You may also bring a lunch; we have a microwave and refrigerator that you are welcome to use. (Please label anything you put in the refrigerator with your name.) Out of consideration for other patients, please do not bring foods that have strong odors.

To pass the time during treatment, you may want to bring a book or magazine. We also have televisions and VCRs, and you are welcome to bring your own videos or pick one from the department’s video library. CD and tape players (with headphones) are fine, as are laptop computers. As the Department of Medical Oncology is located on a below-ground floor, please note that cell phone use is not reliable.

Visitors are welcome to join you during treatment, although we request that you bring only one or two people as our space is limited. Most chemotherapy programs do not require medications that cause drowsiness, so in most cases you will be able to drive yourself home from treatment.
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The Treatment Process

Checking In and Getting Settled

When you arrive for your chemotherapy treatment, you should first check in at the Department of Medical Oncology reception desk. As noted above, you should have already had your blood drawn in the 24 hours before the appointment (except for before your first treatment). If you have not had blood work done, please go to the laboratory and do so before checking in at the Department of Medical Oncology.

At some appointments, you will be scheduled to see your oncologist before receiving treatment. On these days, a medical assistant will escort you from the reception area and measure your blood pressure, pulse and weight. Your physician will then examine you, evaluate your blood work and discuss your treatment progress. These meetings are also a time for you to raise concerns or ask questions about your treatment, and to address issues such as getting prescription refills or completing insurance forms. You may find it helpful to prepare a list of questions in advance so that nothing is forgotten. After the examination, a staff member will escort you to the Chemotherapy Suite.

If your appointment that day does not include a visit with your physician, you will be taken directly to the Chemotherapy Suite after checking in. If you have any concerns or questions at these appointments, one of our registered nurses will be happy to help you.

At every appointment, you will be asked to confirm your name and treatment program before chemotherapy is given, as a "double check" to assure you receive the correct treatment. Please alert a staff member immediately if your information is incorrect.

Receiving Chemotherapy
At PAMF, registered nurses with special training administer all chemotherapy drugs. After you have been comfortably seated in a chair or bed, the nurse will set up the intravenous line (IV) through which you will receive chemotherapy drugs by inserting a needle into a vein in your hand or forearm. (A heating pad will sometimes be placed around your arm first to bring the veins to the surface.) How easy it is to insert the needle depends on several factors, including how often your veins are punctured and whether they are irritated by previous chemotherapy treatments. Our nurses are highly skilled at IV insertion and will do their best not to hurt you. However, if you are concerned about your veins from past experience or are afraid of needles, please let us know.

Besides being hydrated and warm, you can make needle insertion less frightening by breathing deeply, distracting yourself with television or a book, talking with a support person, meditating or listening to music. If these tactics do not work, we can also give you an anti-anxiety medication 20 to 30 minutes before starting the IV. (You will need someone else to drive you home after treatment in this case.)

Your physician calculates the dosage of chemotherapy medications according to your height and weight. The nurse draws up these doses and administers them to you in one of two ways:

• Intravenous push (IVP): Chemotherapy drugs are pushed from a syringe directly into the needle in your vein, either with or without a bag of fluid to dilute the medication.
  
• Intravenous drip or infusion: Chemotherapy is diluted into a bag of fluid and drips into the vein at a specified rate.

You may feel some coolness as the chemotherapy is administered. If the sensation is painful, please advise the nurse.

Once the treatment is completed, the IV needle will be removed, and a pressure dressing applied. You may remove this dressing after 30 minutes.

You will be sent home with instructions specific to your treatment and information on when to return to the doctor’s office, what tests you may require and any required prescriptions. Make sure you do not leave without this information! Please also remember to make your next appointment with the receptionist on the way out.
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After Treatment

There is no rule about what you can or cannot do immediately after treatment. Experience will tell you what is best for you. Most people can usually go about their normal routines, but pace yourself and allow for quiet time. It is best not to engage in heavy activity the first day or two after treatment. Let your body be your guide.

You may feel tired for the first few days after treatment, or experience aches and "flu-like" symptoms. You can take Tylenol® (acetaminophen) for any discomfort, but should not take aspirin while on chemotherapy unless it has been approved by your medical providers. Once you feel well enough, increase your activity/exercise to your normal level.

It is best to eat small, light meals for the first few days after treatment. It is also important to drink six to eight 8-oz. glasses of fluid a day for 72 hours after treatment, which helps to flush the kidneys and clear the byproducts of the chemotherapy from your body. For further suggestions, see the handout on Dietary Guidelines.

Make sure you take anti-nausea medications as directed. Some of these medicines may cause constipation, which can make nausea worse. As a result, if constipation occurs, you can use an over-the-counter stool softener once or twice a day. If you need a stronger laxative, we recommend you take one or two pills of Senokot-S (also sold without a prescription) once or twice a day. If you have not had a bowel movement after three days, call the nurse for further instructions.
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Side Effects

Chemotherapy does not just affect the cancer cells. Normal cells can also be affected, particularly those that divide and reproduce quickly. Examples are:

Bone marrow: Because blood cells are manufactured in the marrow, chemotherapy can cause a temporary decrease in white blood cells, which help fight infection; red cells, which carry oxygen through the body; or platelets, which help blood to clot. We will discuss individually how this affects you. More information on the effect of chemotherapy on the immune system is provided below.

Mucous membranes: Chemotherapy may affect production of these cells in your mouth, throat and digestive tract.

Hair follicles: Hair loss is usual to some degree with almost all chemotherapy. We will discuss with you how much hair loss is expected with your treatment program and give you information on wigs.

Reproductive system: Many chemotherapy drugs affect production of sperm in men and eggs in women. Women may also experience menopause-like symptoms caused by hormone fluctuations, which may be temporary or permanent. These changes do not affect your ability to function sexually.

It is not known what chemotherapy does to sperm and eggs. If you are of childbearing age, practice reliable birth control while on treatment and for several months after completion. Ask your physician or nurse how chemotherapy might affect your particular reproductive health. Men may also wish to ask if "sperm banking" is recommended.

The "Chemotherapy and You" booklet that you have been provided offers further information on side effects. It is also important to remember that difficulty in tolerating chemotherapy drugs does not mean that they are not working against cancer.
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Impact on Your Immune System

As noted above, chemotherapy affects the production of white blood cells in the bone marrow. We will tell you when your white blood cell count will be at the lowest point − called "neutropenia" or "nadir" – on your specific program. During this time, your body’s normal immune system defense mechanisms are less effective, a temporary effect while you are on treatment. You may be instructed to have your blood drawn at the "nadir" after your first treatment so that we can gauge whether your chemotherapy dosage should be adjusted based on how low your white blood cell counts have dropped.

While you are receiving chemotherapy, some simple precautions should be followed:

Wash your hands: Use warm water and regular soap (special soap is not needed) to clean your hands frequently, especially before eating and after using the bathroom. You should also wash your hands after cleaning up pet litter and waste, and wear gloves when gardening. Avoid contact with people who have colds or other infectious illnesses, and don’t share food or beverages with others.

Oral care: Take care of your gums and brush your teeth with a soft toothbrush after every meal. Do not have any dental work done when your blood counts are at their lowest point. As a general rule, dental work is safe until five days before a treatment and then after five days following the treatment. (For further instructions, see the separate handout on oral care.)

Drink fluids: Fluids flush out the kidneys and bladder and prevent bladder infections.

Avoid crowds: You can’t stay away from everything, but if possible it is best to avoid places where there are lots of people and re-circulated air (such as movie theaters or airplanes). It is fine to be around your family members.

Skin: Wash gently. Cuts and scrapes should be washed with warm, soapy water, and you should apply anti-bacterial ointment. If the area becomes red, swollen or “hot,” please notify the Department of Medical Oncology.

Genital/rectal areas: Cleanse these areas gently. You should not use rectal suppositories or enemas while you white blood cell counts are low. Prevent constipation, which can cause small tears (from straining) inside the rectum that can become infected by bacteria. Women should cleanse from front to back after urinating, to avoid bacterial contamination. If you are menstruating, tampons should be changed every four hours, and a pad used at night.

Sexual contact is fine while on treatment. During neutropenia, women may want to use a water-based lubricant to prevent vaginal irritation and ask their male partners to use a condom during intercourse. Do not use vaginal douches for cleansing.

Despite these precautions, you cannot always prevent infection. Bacteria can grow more easily when your immune system is compromised.

During this time, some patients may also receive medications to "boost" the immune system. These medications, called "granulocyte colony stimulating factors" (GCS-F), are given as an injection or shot in the arm. Depending on which factor is used, the medication may be given as one injection the day after treatment, or several days of injections. We will tell you if GCS-F will be used as part of your chemotherapy program.

If you develop a fever of 100.2ºF or greater, call the Department of Medical Oncology or on-call oncologist.
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What to Do if You Experience a Medical Problem

During Office Hours
Our office is open from 9 a.m. to 5 p.m., Monday through Friday. We are closed on weekends and major holidays. Our phone number is 650- 853-2905.

Urgent Medical Problems
When you call the Department, advise the receptionist of the nature of your call. If you are medically ill and require urgent attention, your call will receive the highest priority, and a nurse will speak with you as soon as possible.

Urgent medical problems while on chemotherapy include the following:

• Fever of 100.2ºF or greater
  
• Teeth rattling, shaking and chills
  
• Vomiting unrelieved by anti-nausea medication, with inability to eat or drink fluids
  
• Dizziness or feeling of being faint or weak
  
• Watery diarrhea more than four times a day
  
• Constipation without bowel movement for more than four days, with abdominal pain or discomfort
  
• Burning or pain with urination
  
• Coughing up green-colored phlegm or having green nasal secretions
  
• Shortness of breath
  
• Unusual or prolonged bleeding, blood in urine, oozing of blood from gums or nose
  
• Black or blood bowel movements
  
• New onset of pain, or pain unrelieved by medication
  
• Mouth sores with inability to eat or drink fluids

If you have an urgent problem, report it as early as possible in the day, rather than waiting to see if it resolves. We will treat you that day, and we can better do so when the office is open and we have all of the PAMF departments available. If you call and do not hear back from us within an hour, call us back. Don’t wait!

Non-Urgent Calls
When you call the Department of Medical Oncology with a medical problem or concern that is not urgent, you will likely be sent to voicemail. Our nurses listen to the voicemail throughout the day and prioritize calls according to urgency. We return many of the non-urgent calls at the end of the day, or – if we need to consult with a physician – the following business day. We will get back to you as quickly as possible, so please do not leave multiple messages.

Please leave a clear message, with spelling of your name, your birth date and the name of the doctor treating you. Please also provide a phone number where you can be reached, or let us know if we can leave a confidential message on your voicemail or speak to a family member on your behalf.

Examples of non-urgent concerns include the following:

• Fatigue without shortness of breath
  
• Insomnia (inability to sleep)
  
• Mild diarrhea (less than three times/day) or constipation lasting less than three days
  
• Mouth sores that may require a prescription to treat, but that do not keep you from eating soft foods or swallowing fluids
  
• Nausea without vomiting if you are drinking at least five to six 8-oz. glasses of fluid a day
  
• Lack of appetite
  
• Heartburn
  
• Questions about treatment program or test results
  
• Questions about insurance forms or prescriptions

Many of your questions can be answered by the nurse. If you would still like to speak with your physician, please let the nurse know, and leave a time when and phone number where you can be easily reached. Depending on the nature of your concern, the physician will try to call you within 24 to 48 hours, sometimes during non-office hours if necessary.

After Hours
Even when the Department of Medical Oncology offices are closed, an oncologist is on call. If you have a problem that requires urgent medical care, call the main PAMF number at 650-321-4121. The operator can page the on-call oncologist for you.

As the oncologist may not be the physician who has personally treated you, it will help if you can provide him or her with the following information:

• The name of your doctor
  
• Your diagnosis
  
• Any other major medical condition that you have
  
• Chemotherapy treatment program and date of last treatment
  
• Your symptoms
  
• Your temperature
  
• Name and phone number for the 24-hour pharmacy nearest to your current location

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Medication Refills

If you need a refill, please contact the pharmacy where the prescription was first filled. The pharmacy phone number, refill code and number of refills remaining are listed on the medication label. If you have refills remaining, the pharmacy will provide new medication for you. If you do not have refills remaining, the pharmacy can contact our office for refill authorization; please allow two to three days in this case.

If you would like a prescription called to a different pharmacy, please call us and leave a detailed voicemail message with your medication type and dosage, and the name and number of the pharmacy you would like us to call. If you need a written prescription to send to a mail-order pharmacy, please allow us 24 to 48 hours; we will mail the prescription to your home address.

Some prescriptions and medications are not covered by insurance. These medications may require "pre-authorization: from your insurance company or substitution of a similar medication. Let us know if you have been prescribed a medication that is difficult for you to pay for, so that we can determine the best action in this case. In addition, some prescriptions (such as many pain medications), require the physician to complete a special "triplicate" form to authorize their use. If you require a refill on one of these medications, please call us directly 24 hours in advance. You or a representative will need to pick the new prescription form at our office within seven days.

Plan ahead for refills – don’t wait until your supply is critically low.

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Summary

Cancer treatment is something that nobody wants to face. It is distressing to you and all who care about you. It is a disruption in your life, and an emotionally trying time.

When you come to PAMF for cancer treatment, we enter into a partnership with you. We work with you individually to make your treatment as easy as possible. The information provided here is only a guide; your personal treatment plan will be tailored to your own medical and psychological needs. Your experience with treatment will be unique as well.

As you go through your treatment, please keep us informed of problems that you have experienced, so that we can address the issues and make any necessary changes to your treatment. If you desire more information than we have provided, we can help you find support groups, Web sites, books and other resources.

Think of us as your guides. We are part of your support team ― here to make a challenging experience as smooth and easy as possible for you and your loved ones. If there is anything more we can do to help you during this time, please do not hesitate to let us know.
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