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Slide #1
SUZANNE BLISS: Okay. We've got one last presentation on side effects and symptom management. Thank you so much to our speaker for coming late on a Sunday afternoon.
Angelo Garrido is a nurse, she's an oncology nurse practitioner at Tower Hematology Group in Los Angeles, where she works with cancer patients to access and provide a plan of side effects and symptom management. She's done a tremendous number of things. She was on a committee -- she was a committee member of the Oncology Nursing Society's Fatigue 2000 project. And among the many numerous honors she has received throughout her career, she's been recognized by the American Cancer Society for outstanding achievement in public education.
So, Angela, it's all yours. [APPLAUSE]
ANGELA GARRIDO, RN: Thank you very much. Wow, what a wonderful weekend we had, including -- I mean, I've been hearing information I haven't heard in my own educational setup, so it has been absolutely wonderful. I do want to thank you, the Lymphoma Research Foundation for inviting me participating in this program and especially you, all of you, sitting here while the Angels game is going on; that's amazing. And with all the respect to the San Franciscans, go Angels.
Well, thank you so much for staying this late; I promise I'll be very precise and I'll give you the best information that I have in my slides so there'll be -- the goal, my goal is present information related to side effects to the treatments as well symptom management.
Slide #2
As a nurse practitioner, I have a great deal of responsibility to inform my patients as to what kind of treatments they are going to be receiving, what side effects and what symptoms they will be having.
And sometimes when I introduce the program, I have to reminding that many of these effects, side effects, may not be happening. But if they do, that we have a variety of choices that we can utilize to treat them and to really the manage the symptom. And that my goal is that you use my information and the medications that we have available to manage the symptom and be one step ahead.
It is important that everybody remembers that chemotherapy will -- every person undergoing chemotherapy will experience a different side effects. They go from mild to moderate to severe. And that for most people, these therapies are temporary and they really finish once you go -- when you're finished with the chemotherapy. The one thing you need to remember -- and I think that throughout the presentations, you've been hearing how the side effects are more prevalent in some drugs, some chemo agents. They're more severe according to the doses, as well as the person. And we don't know what makes one person react in a more severe way than the other one.
Slide #3
The things that you need to remember when you started chemotherapy treatments or any kind of treatment for cancer-related are pretty much number here. Know what side effects. It is very important that you know the medications, the name of the medications as well as what possible side effects and when those side effects are going to be appearing, so you are prepared and you're ready to act before the symptom gets worse.
The second one is you have to pull all the coping strategies that you've had in the past in crisis times and that's very important. Because they can be utilized successfully now. Communication is probably one of the most important, whether your symptom is mild or severe, you need to call your doctor or your nurse. And most of time, in every institution, at least in mine, we the nurse practitioners are the telephone triage people. So you decide how severe the symptom or how urgent is it for you to talk to one of us.
Having the support from your family, friends, local institutions, groups like this, is extremely important too. And always, always discuss the side effects with your health care providers. If you're an institution where physicians are extremely busy and cannot get to you with the questions and all the answers, then you can utilize us, the nurses. Because we are trained, basically, to help you out in that. So we work as a support.
Slide #4
I think everybody understands what chemotherapy is and -- because it is a systemic modality treatment and you will receive effects, side effects from the drug. It usually works from -- you know, systemic means it goes from head to toes, takes care of good and bad cells. And this is why side effects are more prone with certain drugs.
Slide #5
They're carried through the blood and the goals of chemotherapy are curative. They can also be for control of tumor growth. You could use it as a removal of microcells that may wander and go somewhere else and also to relieve certain symptoms, such as pain.
Slide #6
One thing I do have to remind my patients is that the experience of chemotherapy is different for each person. And you could be sitting around -- in the area where I work, there's a treatment area, a big treatment area with individual chairs that recline. And you hear conversations back and forth. And it's up to you whether you want to tune out or tune in. And many times I hear patients receiving advice from other patients who have exactly the same type of tumor.
And I always remind them that you don't know what kind of experience -- you could hear what kind of experience that person has, but you don't know exactly what the pathology report says on that particular tumor. And you'll have heard how many types of lymphoma and how many diverse treatments for different types of lymphoma. So any piece of information you receive, you need to take it with a grain of salt and apply it or discard it. And always take that in consideration.
Slide #7
These are most -- some of the most common side effects. I'm not going to go through all of them, because of the time, so I'm going to focus mostly on the most important ones and the most prevalent.
Slide #8
I'd like to start with fatigue, since I participated in the Fatigue Coalition 2000. We were trained, finally, only two to three years ago. We were able to get all the information from clinical studies on fatigue and that was the most important complaint that we heard from patients who had been diagnosed with cancer and received chemotherapy. So, because it is such a subjective symptom -- in other words, no one can tell you how tired you are -- you would have to describe and define in terms of your quality of life what fatigue is and take it in consideration and then do a little bit of homework.
Slide # 9
There are things you can do about troubleshooting this problem of fatigue and there are things that we can do from the physiological perspective. And one of them is -- the things that you can do is look at your everyday activities, try to conserve the energy, balance your activities, so you're not overwhelming yourself and your body. And I can go on for three hours about this, but we're just going to numbered a few of them.
Slide #10
What causes fatigue? Definitely the illness itself, chemotherapy, the effects of chemotherapy, such as anemia, with a diminish in the red blood cells. If the symptoms are not relieved from -- such as nausea and vomiting or diarrhea, then that can take you to dehydration. And even mild dehydration could be a problem in relation to the fatigue. Medication side effects have to be considered. Hormonal imbalances and emotional stress.
Slide #11
What can you do to manage this fatigue? You can look again at conserving your energy. Ask for help, utilize the resources that you have, whether it's your family or the church or the community where you are to whoever is available to help you out. Eat well and eat well means eat well. And doesn't mean go on a diet or go on a specific diet, because this is a time where you're body's going to need every single piece of nutrient that comes in.
Exercise means just physical activity, increase your physical activity, pace yourself in doing so. Because exercise doesn't mean the Tae Bo type of exercise. That means, by research, we know that walking thirty minutes three times a week will be extremely helpful in getting going with your muscles and keeping you up at a certain level and decreasing the levels of fatigue.
Slide #12
The second thing I want to talk is about the blood counts. This is something, for those of you who had experienced treatments, your doctor -- you pretty much depend on giving us your blood. And you come in, you come in to say hi, we draw blood. You come in to chemo, we draw blood. You come in to see the doctor, we draw blood. And that's extremely important, because the complete blood count is measuring the cells that are in the bone marrow that are going to tell us how toxic this chemo is actually getting you or what kind of toxicity this chemotherapy is giving you.
What I do at work is I provide my patients with a copy of their complete blood count -- I'm going to refer it as a CBC. The first thing we say is "Hello, Mr. Smith, we're going to draw your blood. And we're going to look at your CBC. Depending on what your CBC is, we're going to straight to the treatment or call your doctor for any changes."
There is a series of numbers, when you look at your CBC and the three most important numbers that you've been hearing throughout the presentations are -- we need to look at the red blood cells and when those red blood cells are low, then you have become anemic. When the white cells, white blood cells are low, then we have a problem with neutropenia. And when the platelets are low, we have a problem of thrombocytopenia. And you've heard the term several times today.
Slide #13
What is neutropenia? So everybody's heard the presenters before me about talking about the absolute neutrophil count and how important that we measure it. And it's extremely important before we actually treat you. Now, on different therapies, we know when these counts are going to drop. Usually, it's on the seven through the ten day and that's when we usually monitor your counts. That's when we ask you to come back and see us for blood work. When these blood cells are low, then they're decreasing your immune system and they're leaving your immune system a little bit more unattended. And you need to be protected and we need to tell you how to protect yourself against anything outside.
Slide #14
Seven years ago, we used to wait until you had fevers, chills and sweats. And this was just sort of a very aggressive way for your immune system fighting this -- anything enters in your body and not having enough white cells. We used to hospitalize you, put you on antibiotics, pray to God that you responded well to antibiotics and then bring you out of the hospital for the next treatment. Thanks to the technology and the medicine and all the new things that we have discovered, we have drugs -- and I'll talk a little bit more about that -- that will prophylactically help you when those white cells are low.
Any of these symptoms such as diarrhea, urinary tract infections or initiation of upper respiratory infections, they are reasons for a call to your doctor, especially if you know that your counts are dropping at a certain level and these problems appear then. So it is important you keep that in mind.
Slide #15
When you are neutropenic, again, years ago, we used to cover the patients with mask and wraps and protect them almost in a bubble so nobody will look at them bad and get sick and it was really bizarre. And I think that anybody who is going to read the Evans book from yesterday, you're going to see that at the end, on the last page, he says symptoms may be much better now, because they didn't have all the growth factors that they have now. So that's a little bit more helpful.
But the one thing I tell my patients -- and among my patients, I could have teachers or mothers who are taking care of little childrens and so on. And we can't isolate them; we can't just tell them not to hug the little baby before they go to bed, because they're afraid of getting sick. But one thing that we always tell them is wash your hands with soap and water and I think everybody -- it's just that one term that, at least my daughter who's three years will memorize that very well. So I hope not to make her compulsive.
Slide #16
The next thing I want to talk is about thrombocytopenia. It's a medical term that refers to a low platelet count. You heard a lot of the presenters talking about the therapy not being given if the platelets were less than 100. That is a great number and that's sort of the magic number for most institutions. Anything less than 100, we have to reconsider whether we do the treatment or not; it depends on where you are, what kind of phase of a treatment you are, what cycle you are. But anything less than 40,000 platelets, that's a little bit more critical and we need to watch you. Anything then 25, and my institution will transfuse with blood -- with platelet transfusion.
Slide #17
The symptoms are unexpected bruising, red small spots under the skin that they're called in the medical term petechiae and these are not what we call the liver points or spots. No, they're like little tiny red dots that appeared out of nowhere and if we go and check the platelets and you're low, that is a symptom that needs to be addressed.
If there's blood in the urine, it has to be also, a call to your physician or your nurse. Any other symptoms that may have blood in there, there could be a possibility of low platelets.
Slide #18
What can you do when you have a low platelet count? You can avoid any kind of trauma anywhere in your body. Do not use razors to shave, use extra-soft toothbrushes, be careful not to put yourself in a situation where you can accidentally hurt yourself. And these are -- again, the problem is that these are the cells that work very linked in together with the coagulation system. And if they're not effectively working, they're going to allow you to bleed, and this is why we get a little psycho about low platelets.
Slide #19
The next thing I want to talk is about anemia, which refers to a low red blood cell. And in the red blood cells, you find two big occupants of that cell, if I could say that.
And they are the hemoglobin and the hematocrit.
Slide #20
And the one we look at closely is the hemoglobin, because the hemoglobin has the oxygen that carries to all over the tissues and provide that oxygen so your body can function properly.
Whenever you're anemic, some people may feel it at one drop in one point. Some people may feel it at four points. It depends on how your body's working. But if you have a baseline anemia, one drop, one point drop may not be that significant.
Slide #21
I will explain a little bit about the hemoglobin. The connection between fatigue and the red cells. It basically is because if you don't have enough oxygenation in your body, because your red cells are diminished by the treatment you're receiving, then you're in trouble. And the anemia may appear and then you have a little bit more of shortness of breath and you may have a little bit more of fatigue. And that, all that is related.
Slide #22
Now how do we treat all those problems? As I said, we have something called growth factors, and some of these words are probably familiar to you.
For the production of white cells, we have three different growth factors, one is the GCSF of the Neupogen, which you probably have heard the term. The GM-CSF, which our last presenter was talking a little bit in clinical research, and that also produces an increase in white cells.
And the new one, which is the pegfilgrastim or Neulasta, also produced by Amgen. It has a longer half-life and you can be getting this medication a day after your chemo and take it without having to receive any more medication for fourteen days, which actually is going to fall if your white cells are going to drop between the seven through the ten days. Actually going to protect you throughout those days. And that's why your quality of life has been able to improve.
For the red cells, we have a poietin alpha or Procrit. Many of you have probably seen it or heard about it. The newest is a longer half-life also that can be given every two weeks and that's called darbepoetin and it's also called Aranesp.
And for platelets, we have a growth factor called Neumega and that's another drug that we utilize as well.
Slide #23
Changing a little bit, we're going to talk about skin and hair. Unfortunately most of these chemotherapies affect your skin, some drugs. And this is why it's so important that you know what side effects are more prevalent for that particular drug. There are drugs that give you skin problems, either with peeling of the skin or a rash or swelling. And these are things that you need to know so you're not panicking that these things are happening to you and you have no idea where that's coming from. The hair could thin out and there are drugs such as adriamycin that may cause hair loss and the possibility and probability of that happening is pretty high.
Slide #24
What can you do to protect your skin? I will observe, do your physical, own physical exam when you're in the bathroom. Go on every inch in your body, when you're taking that shower so you discover or reassure yourself that there's nothing new appearing. Always use creams and moisturizers and don't use the Clinique type of product -- and I'm not giving a bad rap to Clinique. But I'm saying moisturizer, something that humidify your skin is much better than the ones that smell. And sometimes the smell is very hard on patients receiving chemotherapy.
Protect yourself from the sun. There are a lot of the drugs that are given in lymphoma that could cause recall radiation and that's the formation of blisters and skin reaction from chemotherapy. So it's very important that if you're going to be going outside, gardening or doing things for long periods of time under the sun, that you cover yourself with a hat, long sleeves, tons of sunscreen, especially in the summertime.
Slide #25
I recommend, when I know that a patient is having medication that will cause the hair loss that they get prepared and there's a lot of psychosocial involvement in that for both men and women. And I think it is important that we talk a little bit and we just not address it and go. And if anybody here wants to create a formula to prevent hair loss, you call me, we'll become wealthy and we will have to just not worry about anything else.
There's absolutely nothing right now that is going on in creating something new to prevent hair loss. So it's an important issue.
Slide #26
Let me just touch a little bit more on nausea and vomiting, which are part of the digestive problems that you could have from chemotherapy. As I said before, chemotherapy actually works on every part of your body; it doesn't only target the tumor, but it goes everywhere. And this is why chemotherapy will give you side effects, such as nausea and vomiting.
Slide #27
Nausea and vomiting is an unpleasant side effect that can be controlled. It could occur a few minutes after or a few hours after the treatment or it could be delay, delayed nausea and vomiting, which could happen around third to the fourth day.
Slide #28
When I started oncology, I remember seeing my patients, we all had to have rooms where there were beds. Because we would be loading the patients on Ativan and Reglan and all these drugs that cause all the central nervous system problems and they will be sleeping for days and days and days. The will come back up, have a good week and then dope them again with all those medications just to make them not vomit.
Now we have the 5HD3 antagonists and maybe you've heard words such as Zofran or Kytril. And these are drugs that have no effect in the central nervous system that provide you with an excellent coverage on antinausea medication. And that in combination with old drugs such as Compazine or Ativan, work very, very effectively.
So whenever you are going to start a therapy, ask your doctor if you need antinausea medication. 90% of the times, you will. And depending again, what drug you're going to be receiving, make sure you have a prescription to go home with. And because these drugs are very expensive, then pharmaceutical companies provide us with samples and we give patients samples for the first few days or whatever that time for nausea will come.
It is important that you practice relaxation techniques. And I think everybody has heard the word guided imagery? We provide our patients with CDs and tapes that help you sort of visualize a more positive experience to this. Avoid big meals, always drink fluids. The best thing you can do, if you don't eat for the first week, you'll recover your appetite. But drinking fluids and maintaining certain amount of hydration is probably the best thing you can do in that first week. Because any effect that you may experience in that first week -- shown by research -- will be probably related to the chemotherapy.
Slide #29
The other digestive symptoms that may occurred is diarrhea or constipation. And again, it depends on the agent. But be prepared. Ask for these things. Ask questions about this. There's, for example, a drug in colon cancer that the main side effect is diarrhea. And we need to equip our patients to be prepared for diarrhea, because if they don't, between the nausea and the diarrhea, they're going to end up in the hospital. And if we don't do a good job in telling them what to do when these problems come up, then we should be the ones getting in trouble. And I think that that's why I'm such an advocate for patient education.
When you experience diarrhea, one of the things that we recommend is the first thing you need to do is change your diet. Because there's else hurting your digestive tract and it is important that you maintain that hydration. And if you cannot do a good job by just drinking, then you need to call your doctor and that's where I play an important role in my office, because as a nurse practitioner, I couldn't make that decision. So if you tell me you've tried everything for the last 24 hours, you're vomiting and you're having diarrhea and you can't keep up with life in general, that's an emergency and I want to make sure that you're going to start feeling better. So I'm going to bring into the office, I'm going to hydrate you and help you out for that.
But for that, that's antidiarrheal medication. You can take over-the-counter or you can take prescription and there's steps that we follow in order to help you with the diarrhea.
Slide #30
Avoid high-fiber foods and drink plenty of fluids, and that's probably one of the most important things.
Slide # 31
For constipation, many of my patients, including me, I guess -- have constipation problems. No, I'm kidding. Constipation problems is a big problem as well and if you're taking medications for pain as well, that's going to make it even worse. So, address that question.
Some of these drugs cause constipation. There's a drug called vincristine that is part of the CHOP protocol. And that could give you constipation and it could be from mild to severe. So you need to be prepared and well-equipped to know that this is a problem and that you need to talk to your doctor about it.
Slide #32
Losing your appetite is probably one of the most common side effects of chemotherapy. And it is important that we know that, because if you don't put calories in your body, then the whole train and emotional and physical concerns that your body is having, they are just going to go out in the trash and you're going to feel very, very bad. So it is important we know that.
Some of these chemotherapy agents may change, alter your taste. And things that used to taste good don't taste good any more, and that's totally going to decrease your appetite. So you need to sort of try different things, but not give up. And I think that that's important message.
Slide #33
Some of this chemotherapy could also affect your mouth, the inside of your mouth. You know, your mouth is not protected and it's just a mucosa. And we have tons of ugly yucky stuff in the mouth. And when those things get to grow, they grow really bad. And I think that if anybody has ever had the cold fever sore type of thing, they hurt like crazy.
And if you have this type of bacterial or viral infection, it's not going to let you eat or drink. And it's just going to make you feel miserable; you're going to be in pain. And if you're going to let it go, it's going to get much worse and it might require a much more drastic treatment.
So my point here is not to scare you. It's to let you know that the sooner you act and the more you know about you side effects, the better you're going to be.
So if you start with a sore throat. You call me and I know that seven days ago you had a chemotherapy that might give you mouth sores. I'm going to give you a medication, I'm going to prepare you and equip you with things that you're going to be starting. So we prevent it from making it worse and maybe healing the mucosa as well. So all this is important information you need to have.
Slide #34
We always recommend that you see your dentist before your treatment. That if there are any -- every six months or every three months, root canals or deep cleaning and -- I love those words. They scare the heck out of me, but deep cleaning or something that makes you go in and do all this weird stuff that they do in the mouth. You need to let your doctor know and you need to make sure that your white cells are good. Because that's what's going to protect you from making it worse. So it's very important you do that.
Brush after every meal. Use a soft toothbrush. Never let your lips crack. Always for recommendations; we have ten varieties that we go through when you have a problem such as mucositis.
Slide #35
One thing I want to switch to, which usually is not a side effect of a drug, but it is a symptom of a drug, such as Rituxan or CamPath, any of those monoclonal antibodies. Is the word hypersensitivity reaction. And one of my friends heard that I was going to be presenting this and she mentioned -- she said, "Make sure you talk about that, because everybody talks about side effects and no one says anything about hypersensitivity reactions." And this is important you know that.
When we ask if you're allergic to anything, and you say, "Yes, I'm allergic to penicillin. "What happens when you take penicillin?" "I break in a rash, get short of breath, congested and my chest hurts." That's a hypersensitivity reaction.
So what's happening is that your body is reacting, your immune system is reacting. It recognizes the self from the non-self. What it does, it creates a reaction, a histamine reaction when something goes into your body and it doesn't recognize it as its own. So it decides to destroy it. But when that immune system doesn't work that well, that's when we have the growth of everything else.
Slide #36
Now, when you receive monoclonal antibodies, let me just go over this.
There are four types of hypersensitivity reactions and the one that we have protocols in every institution. When we give monoclonal antibodies will be the type 1, which could be an immediate reaction or it could be a delayed reaction.
Slide #37
The immediate reaction happens within the fifteen to twenty minutes of you getting the infusion.
So monoclonals, it has been described -- and I'm not going to go into details. When your body creates those antibodies of things that are happening in you that are attacking the immune system, then you're going to have, possibly, an hypersensitivity reaction. And there is no way that we know who does and who doesn't. There's no blood work, there's no pictures, there's no X-rays that would tell me if one patient reacts why the other one doesn't.
So we have a pretty strict protocol and probably in every institution, their rule is that you take vital signs every fifteen minutes for the first hour. That we observe, that we ask you, "Are you okay? Are you okay?" And that we ask you to -- any changes of symptoms within the next fifteen, twenty minutes -- please let us know.
There are patients that had come up to me and said, "You know, Angela, I started to have this severe lower back pain." And that acute severe back pain while the Rituxan is going in and just a definition of hypersensitivity reaction. So we have a pretty strict protocol.
Slide #38
The more severe are hives, rash, difficulty breathing and that just goes into a little bit more urgent critical care.
But if anything like that happens, the nice thing is that the first shot of Rituxan or CamPath or any monoclonal antibody that may have hypersensitivity reaction, it's very easily treatable from the very first time. So that's why it's important that you be aware of what's happening to you. If any of this appears, you need to notify the nurse, we need to assess you. Stop the medication immediately and we treat you. And usually treat you with Benadryl, hydrocortisone and in more severe cases, epinephrine and oxygen, but usually that's not the case.
We wait about twenty minutes, wait until the body sucks in all these drugs coming in and then we restart the medication, rechallenge you, rechallenge your body to take it and we start a very slow rate. And this is why when you're making your appointments, you need to know how long is my first treatment? They're going to say six hours, seven hours for your first treatment and then five hours, because your body has recognized that already.
Slide #39
This is more important. When I tell my patients I want you to come in with someone on the first day of your monoclonal antibody infusion, because if you have a reaction, I need someone to be able to drive you in or out of the office if we need to.
Delayed reactions could happen and later than 24 hours, 48 hours, it could happen at home. You could have a skin reaction and call me, "I'm having a skin reaction. And it itches and I can't stop it." And I looked that two days ago you had Rituxan, I'm going to probably treat you with Benadryl and other medications as well. If that doesn't help, then we need to see you and that's how we do that.
Slide #40
So just walking towards the end of my presentation. Whenever you come to see your doctor, come with somebody. Bring all the questions in writing. You know, do your homework before you come in to see him. And whatever you don't get answered, just use your nurse. Because we're qualified to help you on that.
Slide #41
It's important to remember that almost all chemotherapy side effects are temporary and can be managed. Each person's experience is unique. Communicating with us, it's your best tool and your best weapon. And the knowledge that you have -- with knowledge, support and strategies for coping, you have the power to take control.
I had one more slide in my computer. I couldn't transfer it to the CD, but it was -- one of my patients had just finished walking the Avon Walk, and at the end of the race, I guess they have a big flyer that said, "Let Hope Rise." And I think that all of you remembered yesterday, Evan talked about there's no such thing as false hope. And I do believe in that.
The Webster's Dictionary defines "hope" as the expectation of something desired. And I think that every patient that goes through the cancer journey should keep this in their heart, because it's a great tool to keep and carry.
Thank you very much. [APPLAUSE]
FEMALE SPEAKER: [INAUDIBLE]
ANGELA GARRIDO, RN: Yeah, absolutely, if you have any questions, I'll be happy.
Yes?
Q: My name is Jama. And I would like to ask the question that no one else will. No one talks about sex during chemotherapy or after chemotherapy or the fact that it doesn't exist. Could you address that and could, at future forums, we have some information about how to resurrect one's sex life post-chemo?
ANGELA GARRIDO, RN: I -- you know, let me applaud to you, because this is a great, great question and it's a great recommendation also to be able to include that.
When I do my new chemo patients, if I see a couple -- you know, it's sort of a shy thing to do, you know? But it is a very important, extremely important factor to address. If I don't get to address this with my patients in the moment I meet with them, I usually take a look at them at one time in their visits and talk about it.
But I think that sexuality is extremely important. There are chemo agents that will make your sexual life much more difficult for different reasons. In, for example, in the women, some of those chemo agents will take you to postmenopausal changes. And it will change your hormonal balance, so there's no secretions any more and the vagina gets very dry and it gets very painful to have sexual intercourse. And for anybody who's still active, that's extremely devastating.
So, in lymphoma patients, it's a little bit easier to treat that when it gets addressed and I congratulate you for bringing it up and I think it's a very important issue. And when we recognize that it's a problem, if there is no history, for example, in women we put them on hormonal therapy. Or just topical estrogen, for example. With men, we've had this conversation, somehow for men, they're more comfortable with my male doctors to talk about this. But we do have resources and we have medications to help you out as well.
But I think it's an excellent recommendation.
Whose turn?
Q: I had chemotherapy for two and a half months and -- it's almost a month ago. And I am still very tired. Is there a timeframe where I should expect the tiredness to decrease and expect my energy levels to increase? Is there anything like herbs or vitamins or anything like that I should be taking that will help with that?
ANGELA GARRIDO, RN: The answer is yes to all of that, but you said that you finished your chemotherapy completely two months ago. Your cycles are gone.
Q: Well, I'm supposed to be going back on it.
ANGELA GARRIDO, RN: Pardon me?
Q: I'm supposed to be going back on it when my biopsies are healed.
ANGELA GARRIDO, RN: Okay, all right. So the answer is yes. There are many answers to that and you can look into different possibilities. If you have a connection with oncology nurses, they can connect you to websites that can help you assess the problem of fatigue and identify where it comes to. I mean, this is one of the things that requires a conversation.
And when someone tells me -- it used to be that you would tell me, "I am so tired, Angela, and I have been working ten hours a day," and I'll be like, "Oh, so am I. So the two of us are tired, let's do a support group here." But now, I don't do that any more, I just say, "Okay, tell me what that means in your life."
"I am so tired that I have to get a baby-sitter, because I cannot even take care of my children any more." Well, that's extremely drastic and then we take a look at things. We look at your nutritional aspect, at your physical activity, your psychosocial issues, are you extremely preoccupied and worried that you are not sleeping well? Has the chemotherapy changed any of the menopausal status? All these things need to be taken in consideration and it takes a conversation to identify and to pinpoint things that are making your exhaustion and your fatigue much worse.
So my recommendation will be to get an oncology nurse in the area where you are and have her, you know, sit down and talk to her and describe your fatigue and what can you do to make it better. Because there are numerous things that we can guide you through.
Q: I have a question about platelets. When would you be given a platelet booster and how long has it been out and what's its name again?
ANGELA GARRIDO, RN: You know, it's very controversial.
Q: Okay.
ANGELA GARRIDO, RN: This is a drug that is very, very controversial. The doctors where I work, I work with ten physicians and they are sort of iffy about the drug, only because the efficacy hasn't been proven, although if you speak with the company -- it's called Neumega, N-E-U-M-E-G-A. It's usually given in sequence of injections for five to six to seven days until your platelets come up. And you have to be -- you know, I don't use it very often, but you have to have certain level of platelets.
And if we want to try it on you, we'd just evaluate you. If you were my patient and I would want to try it, I would evaluate you. And I would do it only if this will be a consistent problem with every cycle. But if it's only one time that you have low platelets, your platelets drop to 40,000, you're on the second week of your -- after chemotherapy, I'll probably just watch you and bring you into the office every other day just to see what the platelets are doing. But if on the second visit, your platelets go from 40 to 60, then I'm sort of reassured that your bone marrow is doing the job by itself.
It's very controversial and I know -- I forgot the name of the company, but your doctor can give you the name and you can actually look it up, okay?
Q: Okay.
ANGELA GARRIDO, RN: Yes.
Q: Hi, I have a comment and a question. I finished chemotherapy just over a year ago now; it was PACE chemotherapy. And your information is terrific and I had read before the chemotherapy, I knew what to expect. But my comment is to add on to what the woman said earlier about some things that really are not -- a patient isn't prepared for enough. And in addition to the sexual issues are the woman -- you're told you could go into premature menopause. Well, those symptoms are much more severe than a woman who goes through menopause naturally. That I was not prepared for and it was very tough.
Other things such as vascular necrosis, which is associated with the prednisone. Heart toxicity from the adriamycin. You know, it's in the small print, as some of the more serious side effects. Those things I was not prepared for, those long-term side effects. And I think, as a recommendation, patients need to be made more well aware of those potentials and what they really mean. Because they were probably more devastating to me than dealing with ...
ANGELA GARRIDO, RN: Any of this.
Q: ... losing my hair or -- and other things.
ANGELA GARRIDO, RN: Absolutely, absolutely.
Q: So in terms of the long-term side effects, I really don't see much resource available to read -- doctors are so focused on the cure and treating the cancer, when you bring up what seem to be long-term effects of chemotherapy, they're not as focused on that. So is there a place that tracks long-term side effects associated with various chemotherapy agents and is there a source that you can recommend that I could refer to?
ANGELA GARRIDO, RN: You know, you're right. There is not -- I mean, I can't think of anything where I can say, "I'd like you to the website or I'd like you to go to this place and maybe look it up," you're absolutely right. Once you're through with your chemotherapy cycles, I may not see you that often. Because your doctor will be following you up every two months and then three months and so forth. So I think that you make two good points and very well-taken.
My only recommendation and think the only answer I would have, just on the top of my head, will be to use support groups of cancer survivors who have gone out through chemo and then had long-term side effects and discuss them. And then sort of find information as to how would you troubleshoot that.
See the problem is, for example, if you've gone through menopausal symptoms, postmenopausal symptoms or menopausal symptoms with the chemotherapy, took you into menopause without you wanting to go into menopause and now you have all this incredible side effect. Possibilities are that your oncologist may not treat you specifically for that and he or she may refer to a gynecologist or acupuncturist, I don't know, a variety of other physicians. So that sort of comes out of -- it becomes sort of a out-of-boundaries type of thing and that's what will happen.
Unfortunately, I don't know of any -- I don't know if anybody has any ideas of how to answer that question, but the only source I can think of is of patients that have survived cancer with chemotherapy and who may meet monthly, just to discuss if anything new is happening.
Q: Thank you.
Q: I understand that when you have multiple therapies that your immune system is almost like permanently depressed or affected by it. Can you tell me what happens in that case and how it's assessed?
ANGELA GARRIDO, RN: I tell you, while you're going through any of these treatments, your immune system gets suppressed and this is why you could be recovering from the side effects of the chemo and, for example, experience shingles. You're on your third week, ready to have your next cycle and all of a sudden you have the herpes and it hurts and is devastating. And it may be because there's something in your immune system that is suppressing and hasn't come out a 100% better.
And some of this chemotherapy tends to be cumulative as well, so the longer you are on chemotherapy, probably the more affected you may be. Or it could be that nothing will happen to you, but you could be more susceptible to breakdowns in your immune system.
So my recommendation would be, and I understand with all my knowledge has been put on knowing that acupuncture as an alternative therapy may not have the answers for everything. But I think -- in my opinion, just because I lived it personally and also I worked for so many years with cancer patients -- that it does help. It's an adjunct to the protocols and all the millions of critical studies that you have heard yesterday and today.
So be aware that your immune system may be depressed and that maybe things are there that you can look into to make that immune system stronger.
Yes, sir.
Q: Yes, I have several questions, I'm not sure I can ask -- I should ask them all, but --
ANGELA GARRIDO, RN: Okay.
Q: Is that okay?
ANGELA GARRIDO, RN: Yeah.
Q: I've been a patient who -- I've been treating with CHOP and Rituxan on large B-cell. And I'm in remission for a little bit over two years.
ANGELA GARRIDO, RN: Congratulations.
Q: However, there are things that were left over, the things that are supposed to disappear, you know, side effects? And -- that are left over that have to do with the skin, things that have to do with -- that you didn't mention, lymphocytopenia -- low lymphocyte count.
ANGELA GARRIDO, RN: Okay, lymphocyte, yes, mm-hm.
Q: It sort of, it looks like permanent and a little bit crazy.
ANGELA GARRIDO, RN: Is that what your doctor? That it may be a permanent problem?
Q: He doesn't care, he doesn't care to talk about it.
ANGELA GARRIDO, RN: Oh, I'm sorry.
Q: He says it's not important.
ANGELA GARRIDO, RN: Oh, well, I think it is very important to you and you might just ...
Q: You agree, right? Yeah.
ANGELA GARRIDO, RN: Yeah. You might just want to revisit that with your doctor.
Q: Okay. On the, on the -- so that's a -- it's still a low count and it barely is coming up to normal after two years. And I don't understand why -- but it is important, so I will pursue it. The business with skin, there are nails which have been permanently weakened, cracked or they grow ridges, they have a life of their own now. Is that something that can be done -- anything can be done about that?
ANGELA GARRIDO, RN: You know, yes, and I'm not sure how effective the treatments are. I would usually refer you to a dermatologist that I would work very close who understands side effects of all this treatment. Because a lot of these things may be related to fungal infections that may have lingered there and now they're progressing.
Q: You mean that started at treatment time.
ANGELA GARRIDO, RN: Correct, correct.
Q: I see.
ANGELA GARRIDO, RN: You know, it's a much more focused problem than any other things that I said, even though they're very important for individualized patients such as yourself.
So I think that I would try to revisit something that is very important to you with your doctor and try to get an answer. Probably use the Lymphoma Research Foundation to maybe get answers you may not get from your doctor. And certainly followup with different doctors and this is a time when you're going to have a collection of physicians seeing you for different reasons that may not belong to the scope of the oncologist. And the oncologist may be more comfortable referring you to somebody else.
You can look at a book of side effects on one single drug and there could be pages and pages and pages starting from 90% of the patients have this, to 1% but that one percent may be you. So what I'm saying is there are problems that may be associated with the chemo, there are problems that may not be associated with what you went through, but that they required attention and it doesn't necessarily have to be from your oncologist.
I wanted to address the point that you said that it wasn't shown here. And for the sake of time, I mean, I could have gone another two hours on symptom management, but I had to recognize that everybody here is very, very tired and that we needed to just pinpoint the main things.
Q: Right, okay, that's about it.
ANGELA GARRIDO, RN: All right. I can see you here if you want to -- if you have other questions, too. Any more? Thank you so much for staying. [APPLAUSE]
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