Medical Oncology

Advanced cancer
In some cases of advanced cancer, chemotherapy is administered with the aim of destroying cancer cells. However, it is usually administered to shrink the tumour, extend life and improve its quality.

High-dose chemotherapy with transplantation of bone marrow or cells from peripheral tissue
In some types of cancer, high-dose chemotherapy is administered, especially in cases where the initial chemotherapy has shrunk the tumour, but the risk of relapse remains. In this case, however, a substantial part of the bone marrow is destroyed and this is why it is replaced with new marrow cells or blood. The cells intended for the transplantation may be obtained from the patient himself/herself, before the treatment, or from a compatible donor.

How are the drugs administered?
 

• Intravenous injection
• Orally
• Subcutaneous injection
• Lumbar puncture
   

Infusion pumps
Today, infusion pumps are a fairly common method of administering chemotherapy. These portable pumps are available in different kinds and they are used to administer a controlled quantity of the drug into the bloodstream at fixed time intervals.

Administration of drugs by intravenous injection
Sometimes drugs are dissolved in saline. In order to administer the drugs intravenously, the doctor or the nurse must find a suitable vein in your hand or arm and use the technique of venipuncture to place a very thin plastic tube (cannula) through which the drug will enter the bloodstream drop by drop.

Another way of administering intravenous chemotherapy is through a thin plastic tube (central line) placed in a vein in your chest. The most common examples are the Hickman and Groshorg lines. In contrast with the cannula, which is used in a vein in your hand, the central line is placed under local or general anaesthesia. Once placed, this central line is secured well to prevent it from coming out of the vein. It may remain in the vein for several months. In this way, you don’t need to be punctured every time you receive intravenous chemotherapy. It also allows the drawing of blood for the blood tests that you will need to have before and after your chemotherapy.

The two complications that may occur with the use of this line are infection and occlusion. Once or twice a week, the line must be flushed with a drug called heparin, to prevent occlusion due to the coagulation of the blood or with natural saline. Day care nurses can train you how to do this yourself without the risk of infection. You can bathe and you will not have many limitations in your everyday life. Before you go home, make sure that you feel comfortable with the central line and have properly understood how to take care of it. If you have any problems or difficulties, contact your doctor or the nurses at the Centre. As an alternative option, the doctor may decide to place a different kind of central line, which is called peripherally inserted central venous catheter.

Oral administration of drugs
In some cases, chemotherapy can be administrated in tablets or capsules. This means that you can have your treatment at home. You will be given instructions on how and when to take these drugs. If you think that the quantity of drugs you have been supplied with will not be adequate, discuss this with the pharmacist before leaving the hospital. If, for any reason, you cannot take these drugs according to your doctor’s instructions, you will need to discuss this with your doctor.

Where does chemotherapy take place?
Some chemotherapy drugs may be administered during the day at the hospital’s Day Care Unit. For some others, however, a short stay in the Inpatient Department is necessary, perhaps for one or two days or a few weeks. Your doctor and the nurses are happy to explain to you precisely how your treatment will be administered.

Chemotherapy may last from a few hours to a few days. This depends on the type of drugs which have been chosen to treat your cancer. Usually, each treatment is followed by a few weeks of rest, to allow the body to recover from any side effects. The total number of treatments depends on how the cancer responds to the drugs. It could take months to complete your chemotherapy. In case chemotherapy will be administered through a pump, it can be delivered continuously in a given period of time, ranging from a few days to a few weeks.

Some patients receiving oral chemotherapy take smaller doses for weeks and/or months before a period of rest.

 
Before starting chemotherapy, you are usually required to do medical examinations and blood tests. In some cases, you will need x-rays or scans or ultrasound tests which may be repeated from time to time.

All chemotherapy drugs are prepared for each patient separately and therefore you may need to wait for a while until your drugs are prepared by the staff in charge of diluting cytotoxic drugs. Having with you a book or magazines could perhaps be a good idea to spend your time while waiting and relieve feelings of stress.

Your doctor and the nurses can explain to you all the details of your treatment. It would be good if you can make in advance a list of questions you would like to ask. Also, you can be accompanied by a close friend or relative who can remind you of anything you may forget to ask.

Changes in the treatment plan
Your doctor will monitor the effectiveness of chemotherapy (and radiotherapy if you are doing that simultaneously) on a frequent basis. This will require frequent blood and radiology tests. The results of these examinations show the response to the treatment. Sometimes, depending on the results, the doctor may need to change your treatmentif the specific drugs do not cause the cancer to shrink adequately. This is only done with the expectation of achieving better results. Occasionally, the effect of chemotherapy may be delayed because the drugs prevent the bone marrow from functioning properly. This delay gives time to the bone marrow to start functioning properly again.

If you need to attend an important event or want to have a holiday, a change in the chemotherapy plan can be prearranged.

These symptoms usually appear within a few minutes and/or several hours after the chemotherapy and last for a few hours or, in rare cases, a few days.

Some chemotherapy drugs may cause diarrhoea, lack of appetite or
constipation. If you have any of these disorders, discuss the problem with your doctor.

Often, steroids are given together with the chemotherapy injection. The quantity of steroids are too small to cause any damage.

They often give a sense of well-being, while reducing malaise and the lack of appetite (see below). Some patients find that their appetite increases and they put on weight.

Useful nutrition advice

• Nausea and feeling of sickness. Avoid eating or preparing food.
• Avoid heavy or fried food and sauces.
   
•  If the strong smell of cooked food makes you feel nauseous or sick, eat cold or slightly warmed food.
   
• Eat several small meals throughout the day and chew your food well.
   
• Eat something light before the chemotherapy, but not immediately afterwards.
   
• Drink lots of fluids, sip by sip. Avoid drinking large quantities of fluids before the meals.
   
• If you have diarrhoea, avoid foods that contain fibres, fruits, vegetables and milk.
   
• Drink a lot of fluids, except juice, to make up for the fluids lost because of the diarrhoea.
   
• If you have constipation, eat more fibres, fruits and vegetables. Plum juice and hot drinks of ten help.
   
• To keep your mouth fresh and moist, eat small pieces of apple or pineapple.
   

Your mouth
Some drugs may cause mouth ulcers. The ulcers appear five to fifteen days after the administration of the drugs and disappear within three to four weeks. The ulcers may become infected, so your doctor will prescribe the appropriate treatment to prevent or fight the infection.

You may also experience changes in taste. Food may seem more salty or bitter or have a metal taste. Normal taste will come back once the chemotherapy stops.

Useful advice for mouth hygiene

• Clean your mouth and teeth with gentle movements daily, in the morning, noon and evening, using a soft toothbrush.
• Remove and clean your denture daily, in the morning, noon and evening as well as after every meal.
   
• If you feel that the toothpaste has a bad smell or if brushing your teeth makes you nauseous, try a mouthwash (such as a teaspoon of bicarbonate soda diluted in a cup of hot water).
   
• Use dental floss daily.
   
• Keep your lips moist, using products containing Vaseline.
   
• Avoid alcohol, smoking, spices, onion, garlic, vinegar and salty foods as these may increase the abnormal perception of taste and harm your mouth.
   
• Keep your mouth moist. Add light sauces to your food to make swallowing easier and drink at least one and a half litre of fluids (coffee or tea, fruit or vegetable juice and soft drinks).
   
• Avoid sour juices, such as orange and grapefruit and opt for apple juice and cold herbal teas.
   
• Inform your doctor if you have ulcers in the mouth, in order to prevent or fight any infection.
   

Your hair and skin
Alopecia (hair loss) is one of the most well-known side effects of chemotherapy. Some drugs cause minimum hair loss or no hair loss at all. But some others cause partial or total hair loss for a period of time. Moreover, some treatments may destroy the hair, causing alopecia, one or two weeks after you start chemotherapy. If and to what extent your hair will fall depends on the type or combination of your drugs, the dose and the response of your own body.

If you are going to lose your hair, it will start falling a few weeks after you begin treatment, although occasionally it may start to fall in a few days. You may also lose hair in the rest of the body. Your hair will grow back as soon as the treatment finishes.

Useful advice for your hair and skin

• If you are likely to lose your hair from the drugs, you can cut it short before the chemotherapy. Long hair is heavier and therefore falls quicker.
• Use gentle hair products and avoid colour and perm.
   
• Use a children’s brush and brush your hair gently.
   
• Avoid hair dryers and rollers. Dry your hair with a towel with gentle movements, do not rub your hair.
   
• Make sure to look for a wig early, so that it resembles your hair as much as possible.
   
• When shaving use an electric razor to avoid cuts and scratches.
   
• If your skin is dry or itchy, use a moisturising cream.
   
• False nails and manicure can cover the white stripes that may appear on your nails.
   
• When you go out in the sun, wear high protection sunscreen.
   

In specific types of chemotherapy, some patients can protect their hair with a “cold cap”. The cold cap limits the flow and quantity of the drug going to the scalp. Unfortunately, it does not prevent the effect of all drugs. Consult your doctor before using the cold cap.

Some drugs may affect your skin, making it dry or slightly discoloured or cause itchiness. All of this can become worse with swimming, especially if there is chlorine in the water. You must inform your doctor if you have any rash. Your nails may grow at a slower rate and you may see white stripes on them.

Drugs can make your skin more sensitive to sunlight. Protect it with light clothing and sunscreen.

Bone marrow
Chemotherapy can reduce the number of blood cells produced by the bone marrow. The bone marrow is a spongy material found inside the bones and contains blood cells, which usually develop into three different types.

The three types of cells produced by the bone marrow are:

• The white blood cells, which are necessary for fighting infections.
• The red blood cells, which contain haemoglobin to carry oxygen to the whole body.
   
• The platelets, which contribute to the coagulation of the blood and prevent haemorrhage.
   

White blood cells
If the number of white blood cells in the blood is reduced, there is a greater probability of infection, as they are not sufficient to fight microbes.

If your temperature is over 38°0 (Ι00.5°F) or you feel unwell, even though your temperature is normal, inform your doctor immediately.

As the white blood cells are the first line of defence against infections, their action against microbes must be aided with the administration of antibiotics. Your blood tests include a white blood cell count. If there are any changes in your temperature while your white blood cell count is low, you may need to be admitted as an inpatient to receive antibiotics either orally or intravenously.

ΑIn some cases, you may be treated with growth factors to increase the production of white blood cells. This treatment consists of proteins normally produced in the body, and which can now be produced in the laboratory

Sometimes, treatment with growth factors is administered after chemotherapy to stimulate the bone marrow to produce white blood cells at a faster rate. This may help decrease the risk of infections.

The white blood cell count is usually at its lowest from the 7th until the 14th day of the treatment, but this may vary according to the type of chemotherapy.

Red blood cells
If the number of red blood cells (haemoglobin) decreases, you will feel very exhausted. You may also experience shortness of breath as the quantity of oxygen transported throughout your body with the blood decreases. All these are symptoms of anaemia due to low haemoglobin. Haemoglobin is frequently checked with the blood tests you will be having during chemotherapy. Blood transfusion is necessary in case haemoglobin is too low. The right levels of haemoglobin in the blood carry oxygen to bodily tissues at a faster rate, making you feel more energetic and less short of breath.

Many people fear that transfusion may result in the infection of their blood. But this can only occur in extremely rare instances, as both the blood and blood donors are strictly checked.

Platelets
If the platelet count is low, you will have bruises on your body, even with minor injuries, while you nose may often bleed or have haemorrhage even from small cuts. If you bruise or bleed very easily, you must be hospitalised to receive platelet transfusion, so let your doctor know immediately. 
This type of transfusion is similar to blood transfusion, the difference being that the white blood cells and the haemoglobin have been removed. The platelets will immediately start to work, protecting you from bruising and bleeding. Platelets are checked when you do your blood tests.

Useful advice
Inform your doctor immediately if:

• You have fever (temperature of over 38°C or Ι00oF). You may need to receive antibiotics intravenously.
   
• You have bruising or bleeding during or after the chemotherapy.
   

Make sure your body and your environment are clean.

Protect yourself from injuries, e.g. wear gloves when doing gardening.