CHEMOTHERAPY & HORMONE THERAPY

Nearly 2-3 weeks after surgery, once the stitches are removed and the final pathological report of the operation is available, the doctor will decide about hormone therapy, chemotherapy or radiotherapy.

• What is hormone therapy? 
  Hormone therapy consists of a drug called Tamoxifen. This drug is very safe. It has to be taken daily (20mg). The doctor may ask you to take the tablets for five years or even more. You may find some sensation of heat (hot flashes) in the face or body. There may be slight vaginal bleeding at times. Report these to your doctor.
• What is chemotherapy?
  

  Chemotherapy implies treatment with drugs. These are usually injections. The schedules of these drugs are strict and the doctor will tell you in detail about how they are to be taken. Take time to understand the frequency, dose and the gap between two cycles.

  Chemotherapy can be expensive at times. For those who can not afford to buy the drugs the social service department will provide drugs at subsidised rate. You may ask your doctor to refer you to the social worker.

• Does chemotherapy have side effects? 
  The experience with chemotherapy varies from patient to patient. It may cause some unpleasant symptoms. You may have nausea, vomiting, diarrhoea, some abdominal discomfort and weakness. These symptoms decrease considerably within seven days. Your doctor will give medicines to counteract side effect. You may have hair loss, which is always reversible after the chemotherapy is over.
  
  Nausea, vomiting, diarrhoea, abdominal discomfortare short lived and get better with time. The drugs to lessen it are usually given with the chemotherapeutic agents. But if it is troublesome, consult your doctor. If diarrhoea continues beyond a day or is severe, anti-diarrhoeal agents will be required. It is good to take more fluids particularly in between meals. You may find change in the colour of urine (reddish or yellowish) and your nails may turn blue/black because of the drugs. Do not worry.
• What precautions do I need to take while on chemotherapy?
  

  Before each injection your blood will be tested for haemoglobin and WBC (white blood cells, which may decrease due to chemotherapy). If normal then the injections will continue as per the schedule. But the doctor may decide to postpone your injections for sometime if your blood test is not normal to allow the blood cells to recover.

  It is important to take a few precautions while you are on chemotherapy:

  Care of mouth: Brush your teeth gently with a soft toothbrush and wash your mouth with antiseptic mouthwash. Chemotherapy makes the mouth more susceptible to oral infection. If your mouth feels dry, try taking more water and suck ice chips, but if it is very troublesome consult your doctor.

  Fever: Chemotherapy makes you susceptible to infection. If you have high fever with chills, see your doctor urgently. You might need to be admitted in hospital and require injectable antibiotics. Never neglect fever while you are on chemotherapy.

• Diet during treatment
  Eat well & eat healthy food. If you feel nauseated, take small frequent meals. Take less liquid with your meals but liquid intake should be more outside mealtime. Unless otherwise specified, take more of fruits, eggs, pulses, fish, meat and milk. You can try going for a walk before meals to increase your appetite. There are some foods, which may taste bitter. If it is so, try having these with milk or fruits juices. Try drinking as much fluids as possible in between your meals. Avoid taking alcohol as it may interact with your medication.
• Precautions to prevent infections while on chemotherapy? 
  
  1 Eat cooked food.

  2 Raw fruits and vegetables should be thoroughly washed.

  3 Drink boiled or filtered water.

  4 Wash your hands thoroughly, especially before eating.

  5 Use a soft toothbrush and take care of your mouth.

  6 Do not keep your nails long and cut them carefully.

  7 Avoid crowded places where chances of contracting infection are more. You can wear a mask if you wish, but it is not mandatory.

  8 Use lotions rather than a razor to remove hair.

  9 Take a gentle bath and lightly dry the skin with a towel. Do not rub.

  10 Do not ‘fiddle’ with pimples and boils.

• Will I have normal menstrual periods while on chemotherapy? 
  Do not panic if your periods become irregular or stop altogether while you are getting chemotherapy because most of the chemotherapeutic agents stop menstruation. In younger women menstrual cycles may resume after a gap of few months after stopping chemotherapy. On the other hand do not be worried if menstrual cycles continue uninterrupted during chemotherapy.

• Is hair loss permanent ?
  Hair loss is a common side effect of chemotherapy. Some patients may not have hair loss. The hair usually grows back after the treatment is over. Use mild shampoo, a soft hairbrush, and low heat while drying hair. Get a wig or hairpiece before you lose a lot of hair. This way you can match your natural colour and style.

• Will I be able to work during chemotherapy? 
  Most people are able to continue working while they are on chemotherapy. If you wish you can schedule your chemotherapy a day before the weekend so that your work does not suffer.

• Where can I take chemotherapy?
  The choice of place where you wish to take chemotherapy depends on you. You are allowed to take your chemotherapy at your hometown provided there is a competent physician who is willing to administer chemotherapy. We give a detailed letter to your local doctor stating the medicines, dosage and schedules. When you take first chemotherapy you need to observe closely for any undesirable effect that warrants improvisation in dosage and schedules. Chemotherapy should be given only when your blood test is normal.

• How often will I take chemotherapy? 
  The time gap between two shots of chemotherapy depends upon the kind of cancer and the type of medicines. Most chemotherapeutic agents are given every three weeks. If you are receiving CMF regime then two injections are given eight days apart (first day and eighth day) every three weeks. Some patients will be prescribed different regime of drugs, abbreviated as CAF. This regime is administered every three weeks and produces total but temporary hair loss. You have to take all these medicines strictly in time otherwise the drugs might not have the desired effect. If you miss a cycle then contact your doctor.

• Can I take other drugs while on chemotherapy?
  Most of the commonly prescribed drugs can be taken. Very few drugs might interact with chemotherapy. Therefore discuss with your doctor.

RADIATION THERAPY

What is radiation therapy?

Radiotherapy or ‘light’ therapy, as it is commonly known, is used to kill the cancer cells with the help of special rays. A Radiation Oncologist is a specialist who deals with its administration. The patient is given these rays in a special isolated room with the use of a sophisticated machine. The radiation oncologist or physicist will not stand by your side but will be in the adjacent room separated by a glass. He can communicate with you and so can you with him - so don’t be anxious. You will have to lie ‘still’ for few minutes till the radiotherapy is over. The total time spent in the department every day is about 30 minutes.

All patients who have had their breast lump removed, require a 6 - 7 weeks course of radiotherapy.  However if the entire breast is removed (mastectomy) then only few patients require radiotherapy. This treatment is also used sometimes for recurrent cancer and secondary tumours in the bone or brain.

What is the schedule of radiotherapy?
The schedule of radiotherapy is usually five days a week for six weeks, Saturday and Sunday being the rest days. So it is mandatory that you are able to come everyday for six weeks You will be given a specific time between 8.00 am and 5.30 p.m. for daily treatment. The actual treatment is of a few minutes' duration for which you will be left alone in the treatment room under the machine. After the radiotherapy, the breast and surrounding area may feel different and may become firm and dark. You may have some nausea and weakness.

How does radiation work?
The cancerous cells are easily damaged with radiation and slowly decrease in number. The normal cells of the body have a unique ability to withstand moderate repeated doses of radiation and over a period of time they recover almost completely. Therefore repeated daily treatment from Monday to Friday is given for 5 - 7 weeks.

What is radiation planning? 
The Radiation Oncologist will evaluate your disease and explain to you the need for this treatment and its benefits or side effects in your case. Before starting the treatment, the exact area to be treated is determined, marked and measured. A fully computerized technology plans your treatment to protect as much of healthy tissue as possible while destroying the cancerous tissue. The radiotherapy machines are fully shielded to prevent excess radiation to the staff, patients and their relatives. 

This treatment is entirely painless and there is no danger of the patient becoming radioactive. There is no harm in mixing with other people including children. You will be examined by the Radiation Oncologist every week to see the progress of treatment and any side effects.

Precautions to take while on radiotherapy?
It is not possible to avoid some skin reaction due to radiation. The skin becomes warm, red, itchy and sensitive initially and then it may become dark due to pigmentation. In some patients the skin becomes dry, scaly and may also peel off occasionally. 

You can take a bath but do not use any soap, oil, cream or spray over the treated area.

After bath do not rub the skin but gently dab it dry. 

Avoid wearing tight clothing and brassiere during treatment as this may increase the skin reaction. Soft loose cotton clothing is best for this period. 

If the lower neck is being treated then you may experience some discomfort or pain in swallowing. If this happens then you should take soft non-spicy food and you may be prescribed antacid with topical anaesthetic (mucaine) to relieve the pain and restore swallowing.

Sometimes the breast underneath the scar may become firm to hard due to the scarring produced by radiation (fibrosis) after many months or years. 

Remember all these side effects are temporary and gradually recover completely within a few weeks of completing radiotherapy. If you have any doubts or fears please discuss with your Radiation Oncologist.

Can I see my family physician for routine ailments?
Every cough, fever, ache, weakness, should not raise the suspicion of recurrence. Once treated properly you should try to live like a normal person. Do not try to relate each and every problem to cancer. You are as much susceptible to a running nose, cough or fever as any other person. You should see a local physician and take his opinion before rushing to Tata Memorial Hospital. Only when the problem persists in spite of treatment, it needs special attention.

What daily chores can I do at home?
You can normally do all light work at home like combing hair, bathing, walking, driving, gardening, sweeping, washing utensils, and washing clothes. Take care not to do heavy work with the affected arm.

SEX AND PREGNANCY

Permitted while on treatment? 
There is no reason why sexual relations should not be continued while on treatment. Sexual desires vary amongst women on chemotherapy. Some ladies feel closer to their partner with minimal or no decline in sexual urge and energy level. Few others experience reduction in sexual desires partly because of side effects of chemotherapy but mostly due to physical and emotional stress. Some of the causes of stress include fear of cancer, anxiety about future, finance and changes in appearance.

Chemotherapy may induce menopause. You may experience hot flashes and dryness of vagina. Sexual intercourse may then become unpleasant. For lubrication during intercourse, a water based vaginal lubricant is preferable. Lack of secretions may make the vagina prone to infection requiring treatment.

Husband's concern that physical relations will harm a cancer patient or an unfounded fear of 'catching' the cancer from his wife is yet another important cause of deterioration in marital relations. You and your partner should feel free to discuss with nurse, doctor and with each other. Your partner has to realise that intercourse is not the only way of expression of love. Intimate care, kissing, touching, cuddling, and holding are equally important in case you find intercourse difficult. You and your partner together should decide what is pleasant and satisfying to both of you.

Can I conceive while on chemotherapy
No! Conception during chemotherapy is to be avoided as it may cause birth abnormalities in the baby. It is important to practice contraception, using either condoms or IUCD, while on treatment to avoid pregnancy

What if cancer is detected while I am pregnant? 
If you are already pregnant at the time of diagnosis of breast cancer, you should discuss the options before you, with the doctor. Depending on the duration of the pregnancy and the stage of the cancer, the doctor will suggest about how to proceed. Breast cancer may have to be treated differently during pregnancy, and sometimes it is advisable, to have the pregnancy terminated. It is more or less agreed now that pregnancy does not adversely affect breast cancer.

When can I have children?

children?
It is advisable to wait a while after your chemotherapy and radiotherapy have finished before conceiving. The longer you remain free of disease, the lower is the chance of cancer coming back. Therefore, the later you have kids, after being disease free, the better it will be for you.

If you wish pregnancy sooner, then discuss with your doctor.

Does pregnancy lead to recurrence of cancer?
Recent evidence suggests that child bearing has no influence on breast cancer recurrence.

FOLLOW UP

You will be called for follow-up every three to six months. We usually call our patients every six months for the first three years after surgery followed by annual visits thereafter. The purpose of the follow up is to ascertain your disease free status. The doctor will examine you thoroughly. Isotope scans and chest x-ray is not necessary at every visit. Your doctor will advice these tests only when deemed necessary.

What should I notice at follow-up

Lump in operated area

Prolonged cough

Breathlessness

Localised bony pain - back, shoulder, thigh

Gland enlargement in neck

Lump in opposite breast

Progressive swelling of arm

You should see the doctor immediately once you have any of these problems.

 Precautions to prevent swelling of arm 
You may find your arm on the operated side slightly swollen (lymphoedema). If it is excessive, do see a doctor. The swelling may predispose to infection and you should take precautions to avoid injuries to your arm:

You must:

a. Avoid cuts, burns and injury

b. Take any injections on the other arm (avoid the      operated arm).

c. Not wear tight rings and bangles.

d. If you are visiting insect infested areas wear full     sleeved garments to avoid insect bites.

e. use protective gloves while washing, gardening     etc.

f. Practice safe chiropody

g. If you are injured, do not neglect it see a doctor.