General information under cancer information

 

Question.  What is the chemo cycle?

Answer.   A chemotherapy cycle is usually the dose of chemotherapy every 3 weeks.  Most of the chemotherapies are single day treatments. So when we say six cycles it means 6 chemotherapy administrations over 18 weeks.

Few chemotherapy protocols are spread over two to five days, in that situation   chemotherapy requires admission and the next chemotherapy date is counted from the start of the previous cycle. For example, if you receive five days of chemotherapy starting from 1st of June to 5th of June,  the next chemotherapy cycle will come on the 22nd of June and not 26th of June

 

Question.  Is chemotherapy painful?

Answer.    If given through proper and secure IV line, chemotherapy is not painful. There are certain chemotherapy agents which are oil based and may cause pain locally at the time of administration. However such local pain is transient and does not last for long.  Problem comes if chemotherapy is extravasated. These problems are minimised in case you have a chemo port or a picc line.

 

Question.  A word about clinical trials?

Answer.  Many of my patients are very anxious to get enrolled in clinical trials. They  mistakenly believe that clinical trials mean experiments. Patient should understand that when a clinical trial is offered in humans it’s already proven to be effective in controlled conditions like laboratories and there is a high chance that they will receive equally effective treatment.

There are multiple benefits of clinical trials apart from financial support. It allows you to receive drugs which are yet not available to the general population. Patients on clinical trials are under close observation and even minor side-effects are studied in detail.

 

 

                          Management of nausea and vomiting at home

 

This article has been written in simple words for patients to understand and manage nausea, vomiting at home. This article is intended for patients who are currently taking chemotherapy and are developing chemotherapy induced nausea vomiting.  This article is not intended for general population who might develop nausea vomiting because of other reasons.

 

By default all our patients are given clear instructions at the time of discharge regarding management of nausea vomiting, however this article may add to the understanding of the situation and its management. Patients receiving chemotherapy at different Centres can also utilise these simple guidelines, however practice among different oncological centres may vary.

 

In case you are not achieving adequate control of nausea vomiting it is best to contact the oncology Centre which has administered the chemotherapy to you.

 

Firstly understand that the vomiting causing potential (emetogenic potential) varies from regimen to regimen. There are highly emetogenic chemo eg breast chemotherapy with AC with carboplatin more than 1500 MG or cisplatin more than  50 mg. There are other moderate emetogenic drugs. So you should contact your oncology centre for knowing the emetogenic potential of your chemo.

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Secondly you should understand that if it is highly emetogenic chemotherapy then  by default you must have received at least three different group of anti vomiting drugs.  What we usually use is a combination of NK inhibitor, steroid and 5 ht3 inhibitor. The common compound names are aprepitant, dexamethasone and palonosetron.  These details are usually mentioned on your discharge card.

 

Thirdly  check your discharge card for rescue medications.

Usually we mention olanzapine as rescue medication,  other drugs which we utilise are lorazepam or phenargan.

 

Please note that this webpage does not entitle you to purchase drugs without prescription but it is a rough guide on how to utilise the medications which are usually given to you at the time of discharge.

 

The usual mistake which patients commit is inadequate consumption of anti  vomiting medication. They usually take the medications for a day and then stop once they feel comfortable. This results in precipitation of breakthrough vomiting. Once this happens patients get conditioned for chemotherapy associated vomiting and future chances of vomiting increases. This creates a vicious cycle of anticipatory vomiting  and post chemotherapy vomiting.

 

So the first key is to follow your instructions on discharge card as it is. Many a times patients omit afternoon dose considering it is too much of medication and may not be necessary( despite clear instructions from oncological unit).

 

Second common mistake that patients make is upon starting rescue medication they stop the routine medications and take only the rescue medication. This is an obvious mistake because  rescue is supposed to add to the anti vomiting actions of routine medications. Continue the previously mentioned usual doses of anti vomiting drugs like ondansetron or domperidone and take rescue medication as an additional dose.

 

FAQs by patients undergoing chemotherapy

 

Question.  I developed a feeling of nausea vomiting even before starting my chemotherapy.  What can I do?

Answer.  This is anticipatory  vomiting and is usually because of social learning from different media, self perception of chemotherapy being emetogenic. You should understand that with today's anti vomiting drugs vomiting is a thing of past if properly treated. If vomiting is poorly controlled in your first cycle of chemotherapy then it is natural to develop conditioning for anticipatory vomiting from the second cycle onwards.

If you feel nausea vomiting even before starting chemotherapy then you may try non drug methods such as clinical hypnosis, relaxation exercises like guided imagery, yoga and acupressure.  If these are unavailable then your doctor may prescribe medications like lorazepam to be taken one night prior to chemotherapy.

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Question.  I do not like  to swallow so many anti vomiting drugs, I feel full in my stomach.  At the time of nausea taking anti vomiting drugs make me vomit. what can I do in this situation?

Answer.  You can discuss with your oncologist to convert oral anti vomiting drugs to IV form.  Also these days there are longer acting drugs which need to be taken once a week. for example  we often prefer neupitant (once a week) over aprepitant (three doses in a week). Secondly you can use mouth dissolving formulations so that you need not swallow them.  Just keep them under your tongue and within seconds it will get dissolved. It gives faster control also.

 

Question. Continue medications even after prescribed time?

Answer.  Chemotherapy induced vomiting usually lasts for 5 to 7 days only. There is no additional benefit of taking medications meant for chemotherapy induced vomiting after the prescribed  duration. Minority of patients can develop extended delayed chemotherapy induced nausea vomiting and in that case all the drugs need not be continued.

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Question.  Do anti vomiting drugs reduce the efficacy of chemotherapy?

Answer.  No, on the other hand if you take inadequate anti vomiting drugs then we might have to reduce the dose of chemotherapy and that may result in reduced efficacy. If you are regularly taking steroids for some other reason, then you should disclose this to your oncologist If he's planning immunotherapy in your case.

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Question. I feel sleepy after anti vomiting drugs. Is it natural and can I avoid it?

Answer.  Yes, anti vomiting drugs may make you feel sleepy. Usually the drowsiness improves over 2 to 3 days and over subsequent chemotherapy cycles. If this interferes too much with your lifestyle then you may discuss the case with your oncologist. He may choose medications which are less sleep causing or add something which can reduce sedation.

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Question.  I heard about Cannabis oil for vomiting?  Is it true and should I take it?

Answer.  Cannabis oil is not clinically available on prescription. There are various non conventional sources from where patients acquire it. We do not recommend Cannabis oil to our patients because it causes silk and sometimes dependence also.

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Question.   I have followed all the steps but I am still vomiting or feeling nauseous. What can  I do?

Answer.  This could be a case of  refractory breakthrough vomiting episode. In this case it may be difficult to manage with oral medications and you may need IV injections for supportive care like  saline infusion. Rarely patients who have cancer in the abdomen can also have vomiting due to obstruction. However this is rare and vomiting in this case is usually greenish in colour. If this happens you should visit your emergency services at the earliest.

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Just  to mention again,  this is General guideline for patients who are receiving chemotherapy and is not meant for general population who might be having vomiting because of some other reason. Also this page does not entitle you to purchase medications without prescription.

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                            Fever and diarrhoea after 5 days of chemotherapy

 

This is clinically very important topic because after 5 days of chemotherapy chances of  immunity suppression is there depending on the type of chemotherapy taken. This period starts from 5 to 7 days after chemotherapy and lasts till 12th to 14th day. The days are counted from the date of chemotherapy.

 

This one week is clinically very important for prevention as well as treatment of infections.

 

Since this page is for patients, I will be discussing what patients should know and follow.  I will not include scientific details regarding what to be done from a doctor's perspective.

 

However I will include Red flag signs from patients perspective, if present they should they seek medical help immediately.

 

First of all a patient should know if he has received chemotherapy which is severely immunosuppressive or mildly immunosuppressive .Usually when onco physicians administer severely immunosuppressive chemotherapy we prefer to admit the patient for monitoring, example during leukaemia treatment. Majority of chemotherapy for solid cancers example breast cancer or lung cancer is low to moderate immunosuppressive.  the side effects of infections are usually manageable on OPD basis. however patients should understand that because of immune suppression unit small infection can become life threatening the chances are less.

 

Second most important thing is how patient’s family members monitor vitals at home.   Usually I take efforts to explain how to measure fever or to take pulse rate of the patient.  I also recommend patients to own a BP monitoring machine for checking blood pressure at home itself.

 

Caretaker should understand  what is fever? Fever is single temperature measured more than 38.3 degree centigrade or 38.0 degree centigrade for more than 1 hour. Oral temperature should be taken. If taken at armpit then one should 0.5 degree centigrade to the measured temperature.

 

Thirdly it is ideal if caretaker can take pulse rate and blood pressure. Assuming that patient had normal blood pressure before receiving chemotherapy, after 5 days if blood pressure is found to be below 100/60,  the patient should be taken to the hospital for evaluation of possible infection.

 

If the pulse rate is more than 110 it could be indirect indication that infection may be present.  However pulse rate could be high because of other reasons like anaemia also.

 

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Question.  What are the Red flag signs which when present I should go to the hospital?

Answer.   Following are the red flag signs:

• Pulse rate more than 110

• blood pressure less than 100/60

• loose motion more than thrice

• vomiting more than 3 times

• feeling of giddiness  for drowsiness

• inability to consume orally

• breathlessness

• convulsions

• If you are already taking antibiotics for prophylaxis as mentioned below and still developing fever spikes then this is also considered as a red flag sign

 

Question.  What can I do if Red flag signs are not present but I am having fever?

Answer.  Quite often during the period of transient immunosuppression low grade infections can happen, which usually present in the form of mild to moderate fever associated with abdominal symptoms like diarrhoea.

As a part of practice,  we give ready stock of Amoxicillin clavulanic acid and fluoroquinolones for such a situation. Assuming that patient is not allergic to ciprofloxacin or amoxicillin,  the patient with fever should take ciprofloxacin plus amoxicillin and clavulanic acid combination in adequate doses. Doses for more than 40 kg body weight includes ciprofloxacin 500mg 3 times a day and Augmentin 625 mg three times a day.

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It is imperative that you must communicate with your cancer treatment Centre regarding the development.  

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                                                                 Pain control

 

This webpage is meant for patients diagnosed with cancer and have cancer associated pain.  This web page does not entitle you to purchase medications without prescription. The sole purpose of this webpage is information for adequate and appropriate utilisation of pain relieving medications.

 

Pain is a common symptom among cancer patients, almost all cancer patients feel pain at some point of disease management. It is usually caused by the cancer itself but sometimes there are multiple factors which can contribute to pain. Pain which remains for short duration is known as acute pain while long lasting pain is known as chronic pain. The origin of events causing pain may happen in the body but the perception of pain happens at the level of brain. Hence there could be multiple methods by which pain can be addressed.

 

Question.  Why is pain management important?

Answer.  Pain is one of the most distressing symptoms of the patient and greatly reduces the quality of life and defeats the purpose of treatment. Many of my patients who come to me for second opinions are receiving excellent  and most innovative drugs for cancer treatment but their pain symptoms are many a times poorly managed.

 

Question.  Why do you say that pain is often  poorly managed?

Answer.   Pain can be managed in a lot of different ways however I have seen that many of the centres rely heavily on opioids for pain control. Opiates are helpful but need to be used in the correct manner to avoid side effects & optimal benefit.  For example I have seen people offering fentanyl patch or controlled release Morphine tablets in acute painful situation. One should understand that these delayed-release formulations take up to 18 hours to achieve steady state in patients body and for those 18 hours patient will have inadequate pain control.  Not only the pain but the side effects of opiates are also poorly managed. For example, I have seen people getting prescribed for Morphine without any bowel preparation( morphine causes constipation). This results in avoidable constipation and produces a symptom which is unnecessary.

Often other ways or non  pharmacological approaches are neglected by physicians.  Examples include physical therapy, cognitive behaviour therapy, massage or integrative therapies as acupuncture or Acupressure.

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Question.  What are the mistakes on the part of patients and the family in poor management of pain.

Answer.  Patient and family members have an unjustified fear about opioids particularly about addiction. Sadly family members are the usual culprit in this situation. As a result patients don't take appropriate doses at appropriate time resulting in inadequate pain relief and reduced quality of life. One should understand that cancer patient may not have very long to live. In this situation fear of addiction is inappropriate even though  the chances of developing addiction is same as General population.

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Question.  Is there a limitation on the part of  treating physician in inadequate pain control?

Answer.  As I mentioned above non-pharmacological therapies are rarely prescribed.  Apart from that even physicians are afraid of opioid misuse which includes reselling of the drugs, dependence and respiratory depression. In my experience I have never seen a patient undergoing respiratory depression with oral opioids prescribed for clinical pain relief.

Health infrastructure also poses certain limitations . Legal restrictions are there for availability of opioid based compounds, insurance companies many times don't reimburse oral medication.

 

Question.  What are the types of drugs which we can offer besides opioids like morphine

Answer.   A lot of different groups for example Paracetamol is considered to be very safe however it is not a strong pain killer,  other groups include NSAIDs which can be used for moderate pain however chronic use can result in kidney injury.

Choice of pain relieving drugs also depends on the type and the reason of pain for example there are reasons in which pain is because of nerve injury. In such situations sometimes drugs like antidepressants and  nerve suppressants work very well, examples include gabapentin.

Quite often combination of different groups of pain relieving drugs are given to achieve adequate symptom control

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Question.  My doctor has given combination and repairs inadequate doses is still I feel the pain what could be the reason?

Answer.  Sometimes despite all the medical management of pain, inadequate symptom control is achieved. Often the reason is bone or nerve infiltration. In such situations intervention is important, for example if bone is infiltrated, local radiation to that area can give good results. On the other hand if nerve is infiltrated then nerve block can give good results by destroying pain transmitting nerve fibres. It is a  minor procedure but because of lack of interventional anesthesiologist it is less often described.

For Bony pain we also tend to add phosphonate or denosumab. I am personally fond of kitterman to be used as a injunct for pain control in palliative settings. In a minority of patients I have also used lignocaine infusion.

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Question.  I think people don't understand my pain, can I measure it ?

Answer.  Yes, there are simple ways known as visual analogue scale in which you number the degree of pain you are having from 0 to 10  where 0 means no pain while 10 means life threatening pain. After medications the degree of pain and its change is recorded for titration of medications. Biofeedback machines are also available but at very few centres for subjective recording of pain.

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Question.   Round the clock prescription of pain relieving tablets increase the number of tablets I take, can I reduce the number of tablets?

Answer.   Definitely yes, there are many ways to reduce the number of pills to be taken in a day.  Firstly you can take sustain release formulations in morning or evening time. Secondly, you can switch to a stronger opioid so that less dose is enough. Thirdly these days transdermal patches like stickers are also available. However utilisation of all these methods is an art because sudden switch from instant releasing to long acting methods may reduce pain control.

 

Question.  You discussed about constipation caused by painkillers, what to do about it?

Answer.  The most important thing is to know which type of painkillers cause constipation.  For example all opioids are not equal in causing constipation, few are more powerful than others.  Anyhow constipation can be relieved by combining two different type of purgative drugs. I personally use stimulant laxatives like bisacodyl with osmotic purgative like milk of magnesia or poly ethylene glycol . It is ideal to give prophylactic medications to prevent development of constipation. In case of refractory constipation certain other drugs can be used like certain progestins.

Patients who are chronically constipated are more prone for opioid induced constipation.  Similarly old patients are also prone for constipation and other Side effects of opioids.

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Question.  Is constipation the only side effect of opioids?

Answer.  There are few side effects more for example patients can develop itching, nausea or drowsiness. These are managed on a symptomatic basis with medications  which can increase gut motility or with medications used to prevent nausea in chemotherapy patients like ondansetron. If the patient becomes very drowsy it is best to take him to the hospital.

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Question.  Any word of caution regarding pain controlling medication?

Answer.  Actually there are many. Firstly take the medications as prescribed, sometimes patients abuse the drug for side effects example few of my patients start taking  morphine not for pain but to sleep!!! avoid alcohol or other illicit substance while on opioids. Avoid taking NSAIDs for more than 7 days continuously.

Following are the Red flag signs to be observed,  if present medical care in person should be shot at earliest

1. new onset pain or change in the type of pain while on medications. It can have organic reason which needs to be addressed.

2. nausea that prevents normal eating for more than one day

3. Constipation since three days not relieved by above-mentioned measures

4. patient is developing confusion, irritation or extreme drowsiness with difficulty in arousing

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“ there is NO MEDICAL BENEFIT OF TOLERATING pain. Seek help early!

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GCSF stands for Granulocyte Colony Stimulating Factor. Its used to over the neutropenia (low immunity) which occurs usually after 5 days of chemotherapy. Some brand names include pegesta, grafeel etc. Watch a video on how to self inject GCSF at home.

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