Pacific Hematology Oncology Associates
  • Introduction
  • Diarrhea
  • Nausea and Vomiting
  • Fatigue
  • Anti-nausea medication
  • Peripheral Neuropathy
  • Mouth problems
  • Low blood counts
  • Hair loss
  • Prescription refills
  • Constipation

Introduction
At this time, we will be extending the services provided by our office to include chemotherapy. The information that follows is designed to help you become familiar with our office policies and routines concerning chemotherapy. If you have unanswered questions or need additional information or clarification, please ask your physician or nurse. Good communication, as always, remains a vital part of any relationship.

Chemotherapy may be given either in the office or in the hospital. In general, the office setting is preferable. Each set of drugs has different reasons for their use and different potential problems. We do have handouts available for many of the drugs that you may be getting, either alone or in combination. We ask you to request the handouts from our staff and read them as frequently as it seems appropriate.

When you are getting chemotherapy, be sure you are very clear on the appointments that you have. Some will be for chemotherapy only; some will involve a follow-up appointment with a nurse in order to get a blood test and evaluation; some of the appointments will be with the physician only. If there is time, our nurses can make you a calendar with approximate treatment dates. Since the side effects of each set of drugs are different, make sure you know the names of the drugs you are taking, as well as other medicines you may be prescribed, enabling you to be as informed as possible.

Anti-nausea medicines are given along with chemotherapy. The exact type depends on the specific chemotherapy regimen. In some cases you will be prescribed an oral anti-nausea medicine and asked to bring it to the office on the day of treatment. Bruising easily or bleeding from the nose, gums or other sites needs to be reported to us promptly. Fever, especially in the 7 to 14 days after chemotherapy, burning with urination or other potential symptoms of infection, also needs to be reported right away.

In a similar way, it may be important for you to know about the possibility of diarrhea, mouth sores, and other side effects. The nurses and physicians will help teach you what to look out for in order to minimize any discomfort you may feel.

If you are getting radiation therapy, we may want to see you more often in the office to get complete blood counts. It is helpful to let us know what your schedule is so that we may minimize additional trips to the medical center for you.

Telephone calls: 415-923-3012
We encourage you to call our office if you have any questions or concerns regarding medical problems or your treatment. The oncology nurses are available during business hours; you may also leave a voice mail message for them in the event that they are with patients when you call. The office staff may be able to answer appointment related questions. If you require direct communication with your physician, your message will be given to him/her and the call will be returned as quickly as possible.

Evenings and weekends
Our physicians are available by phone 24 hours a day to give you medical care and advice, as well as to meet your emergency needs. Evenings and weekends are for emergencies only; routine questions should be asked during regular office hours. For emergencies, call 415-923-3012 and our answering service will connect you to the physician on call.

Prescriptions and refills
Prescription needs and refills are best taken care of during an office visit. However, if the need arises, you may call during weekday business hours. We cannot renew narcotics on weekends; a special prescription fonT' is required and pharmacies cannot accept those prescriptions over the phone. It is wise to plan ahead for your medication needs.

Billing information
We make every effort to keep down the cost of your medical care. We therefore request that co-payments be made at the time of your visit. Our office will submit insurance forms for outpatient and inpatient services provided by our physicians. Please keep us informed of any insurance changes. You are responsible for following up on delayed insurance payments. You will be sent a monthly statement noting any balance that is your responsibility. Questions that may arise regarding your insurance may be addressed to our insurance personnel. The direct line is 415-923-3105, and you may leave a message if staff is not available when you call.

Please remember that some insurance companies pay a percentage of the charge, and others pay fixed allowances. Our fees are based on the type of service rendered, and may not necessarily agree with the basis used by your insurance company. Regarding chemotherapy, please remember that we have prepaid for all drugs given in our office. Since many of the insurance companies do not pay for all of the chemotherapy costs, and most do not pay in a timely fashion, please be prepared to pay your share of the cost as soon as you receive our bill, which is after your insurance company has paid. If there are any extenuating circumstances, please speak with our office manager.

A final word...
Please remember that you are a participant in your health care. An open exchange of information between you and our staff is extremely important. Please do not hesitate to ask questions or to offer constructive criticism. We are here as a team to serve your health care needs.

What to do about diarrhea
Diarrhea is defined as an abnormal increase in both the number of stools passed and a change in consistency 04' stools from formed to liquid. It may be accompanied by intestinal cramping.

Patients with cancer sometimes experience diarrhea for a variety of reasons. A person's bowel pattern may permanently change after intestinal surgery. Certain chemotherapy medicines affect the motility of the gut, causing an increase in the number of stools per day. Antibiotics can change the balance of normal bacteria in the intestines, resulting in diarrhea. Diarrhea is a common side effect of radiation therapy to the abdomen. Finally, people who are lactose intolerant may have diarrhea after eating dairy products.

If you experience diarrhea, there are a number of steps you can take to minimize complications

Dietary changes

• Replace lost fluid by increasing your intake of liquids. This may include water, tea, ginger ale, Popsicles, Gatorade, broth, Pedialyte, or non-citrus juices

• Follow the BRAT diet: Bananas, white rice, applesauce, non-caffeinated tea and toast

• Eat smaller, more frequent meals

• Avoid foods and beverages at extreme temperatures

• Avoid spicy or fatty foods

• Avoid milk products

• Avoid caffeine

• Avoid nicotine

• If you experience more diarrhea and gas after eating dairy products, avoid them, or replace them with soy or lactose-free products

Medication

Imodium: Available over the counter, lmodium (Ioperamide) may be taken as directed on the package. The usual dose is 2 tablets taken after the first loose bowel movement, followed by 1 tablet after each additional loose bowel movement, not to exceed 8 tablets per day.

• Lomotil: This requires a prescription, and can be helpful in patients whose diarrhea is not relieved by Imodium. The dosage is the same.

• Tincture of Opium: This can be very helpful in severe or chronic diarrhea. It requires a triplicate (handwritten) prescription from your physician.

• Kaopectate and Pepto Bismol should be avoided if you are receiving chemotherapy, since both contain aspirin.

• If you have been taking stool softeners or laxatives prior to the onset of diarrhea, discontinue them until your bowel function returns to your baseline.

Comfort measures

• Clean the rectal area after each bowel movement with mild soap and water or baby wipes

• Soaking in a warm tub may soothe irritated skin in the perianal area

• A hot water bottle or heating pad on the abdomen may help lessen cramping

Let your physician or nurse know if any of the following occur

• Fever over 100.4 degrees Fahrenheit

• Severe abdominal pain

• Inability to drink adequate amounts of fluid

• Weakness or dizziness

• Weight loss

• Blood in the stool, or black, tarry stool

• Rapid heart rate

Feel free to use the above information as a guide, but remember, it is not a substitute for good communication with your health care team. During the day, the oncology nurses are available by phone and voice mail, and a physician is available 24 hours a day and on the weekends, through our main office phone number, (415) 923-3012.

What To Do About Nausea and Vomiting
Nausea and vomiting are among the most widely feared side effects of chemotherapy. While not all chemotherapy drugs cause these problems, it is important for you to know what to do if you experience them. Nausea may begin 3 to 4 hours after chemotherapy is given, and may last 10 to 12 hours or longer, depending on the drugs being administered. Our goal is to prevent vomiting and for you to experience as little discomfort as possible. In most cases, you will be given intravenous anti-nausea medicine at the time of your treatment. In addition, oral anti-nausea medicines will be prescribed for you to have on hand at home. Your nurse or physician will give you written instructions as to how to take these important medicines. It is important to call the physician or nurse if you experience nausea or vomiting that do not respond to the prescription medicines you are given or if you are unable to keep food and fluids down.

The following tips may help you during times of nausea

• Take anti-nausea medicines “round the clock,” on a routine schedule. Anticipate nausea - do not wait for nausea to occur before taking medications. Anti-nausea medicines can cause sedation, especially in combination with other sedating drugs or narcotics, so avoid driving when taking these drugs. You may also experience mouth dryness or feelings of restlessness; call the physician or nurse if restlessness develops.

• Concentrate on nutrient-rich fluids on the day of and 1 - 2 days after chemotherapy. It is probably more important to drink fluids than to eat solid foods at first. Juices, broth, shakes, gelatin, and yogurt contain more calories and nutrients than plain water or tea.

• Avoid sour tastes in the mouth. Rinse your mouth frequently with water, suck on hard candy, or chew gum.

• Avoid strong, unpleasant tastes and odors. Circulate fresh air.

• Try to sleep through times of increqsed nausea.

• When you feel nauseated, avoid hot, spicy, fatty and hard to digest foods. Bland foods often are best tolerated. Smaller, more frequent snacks may be better tolerated than three regular meals.

• If you find that you cannot keep oral medications down, we may prescribe rectal suppositories.

If you ever find that these medications do not help, and vomiting continues, please call our office at (415) 923-3012 day or night and speak with a nurse or your physician to discuss alternative remedies.

What You Can Do About Fatigue
Fatigue in the cancer patient is one of the most common complaints physicians and nurses hear. We define fatigue as an overwhelming lack of energy that has an impact on your daily life activities. You may find that you are unable to do as much during the day as you used to. You may be short of breath, even after light activity. Some people find it difficult to pay attention during conversation, or may have a desire to sleep all the time. For many, this change in energy level can be profoundly depressing.

Fatigue related to cancer can, be caused by many things, including chemotherapy, recovery from surgery, anemia, infection, side effects of medications, radiation therapy, and anxiety. The majority of cancer patients experience fatigue at some point in the course of their disease and its treatment. However, with patience and planning, you can learn ways to conserve your energy and to cope with this common symptom.

Here are some suggestions you may find helpful

Plan and prioritize

• Do the most important tasks of the day first, while your energy is highest.

• Set reasonable goals for a day. If you normally accomplish four things, plan to finish two. Anything extra you get done will be a bonus.

• Accept help from friends and family, and learn to ask for help when you need it.

• Establish good sleep habits. Don't drink caffeine in the evening, and try to limit naps in the daytime to short periods if you can. Try to establish a routine for bedtime that enables you to relax and rest comfortably. If you need to, take pain medicine before sleep to avoid waking up during the night in discomfort.

Meal preparation

• Assemble ingredients and utensils before you start, and sit while you cook. Prepare enough so that you'll have leftovers, and freeze half the meal for later. Use cookware you can serve from, and serve at the counter instead of at the table.

• Store frequently used items within easy reach to avoid bending and stretching.

• Use tools that make tasks easier, like a rubber jar opener, electric can opener, and lightweight utensils. Let dishes soak instead of scrubbing, and air-dry them.

• Consider mixes or prepackaged food as an energy saving option. Order food from a restaurant to be delivered a few days a week.

• Sign up for a meal delivery service. In San Francisco, Meals on Wheels (920-1111), Meals that Heal (4404325) and Kimochi Nutrition (931-2287) provide meals to seniors at little or no cost.

Housekeeping

• Ask for help with the most difficult tasks

• Do a little each day, and spread chores throughout the week

• Organize before you start. Carry dust cloths and sprays in a bucket and complete work in one room at a time. Use mops, brooms and dustpans with long handles to avoid bending.

• Sit to fold laundry

• Wear clothing that does not require ironing, or sit to iron

Remember, prioritize: The dirt will still be there when your energy is higher

Bathing and dressing

• Use a shower stool. These are available in most large drugstores.

• Install a grab rail.

• Avoid extra hot water, which may leave you feeling drained.

• Sit to dry off, or use a terrycloth robe.

• Consider an elevated toilet seat.

• Lay out clothes in advance, and avoid rushing to dress.

• Wear loose fitting clothes that fasten in the front.

• Avoid bending over to put on shoes and socks. Slip on shoes may be easier to put on than lace ups.

In addition to the above suggestions, remember that managing stress and continuing to participate in activities that make you happy will improve your overall quality of life.

A special note about fatigue related to anemia
Anemia is the medical term used to refer to having fewer than normal red blood cells. People with cancer often experience anemia for multiple reasons. Your body may be producing fewer red blood cells than normal as a side effect of chemotherapy. You may have lost blood as a result surgery. In some cases, anemia is due to the underlying disease.

When anemia is severe, your physician may recommend a blood transfusion to rapidly raise your red blood cell level. If you are less severely anemic, she or he may prescribe a medication called Procrit, which is given as a weekly injection under the skin. In either case, your physician will discuss the benefits of either treatment option with you. Remember that there are measures you can take to help deal with fatigue so that it interferes as little as possible with your life.

Anti-Nausea Medication Instructions
When you receive chemotherapy, we often administer intravenous anti-nausea medicines to prevent nausea and/or vomiting. These drugs frequently work to prevent vomiting for up to 24 hours after chemotherapy. Your physician or nurse may recommend oral anti-nausea medicines in addition to help prevent the unpleasant experience of nausea or vomiting from occurring after you leave the office. Below are guidelines for how to take these medicines.

Oral anti-nausea medicines may have side effects of their own. Some patients experience dry mouth and drowsiness following Compazine or Phenergan. It is important not to drive while you are taking these medicines. Drink fluids or suck on hard candies to relieve dry mouth. Decadron can cause insomnia and mood swings. Talk to your physician or nurse if this becomes a problem for you. If, at any time, you experience restlessness, muscle twitching, or neck stiffness after taking any of these medicines, call our office immediately and speak with a physician or nurse.

If you find that you cannot keep oral medications down, we may prescribe rectal suppositories as listed. If you ever find that these medicines do not help, and vomiting continues, please call our office at (415) 923-3012 day or night and speak with a nurse or your physician to discuss alternative remedies.

• Compazine (prochlorperazine) tablets, 10 mg: Take 1 tablet by mouth every 4-6 hours as needed.

• Compazine (prochlorperazine) suppositories, 25 mg: Take 1 suppository rectally every 8 hours as needed.

• Ativan (Iorazepam) tablets, 1 mg: Take 1 tablet by mouth or under the tongue every 4-6 hours as needed.

• Phenergan (promethazine) tablets or suppositories, 25 mg: Take 1 tablet by mouth or 1 suppository rectally every 6-8 hours as needed.

• Decadron (dexamethasone) tablets, 4 mg: Take 2 tablets by mouth 3 times a day the first day after chemotherapy, then 1 tablet 3 times a day for the next 2 days.

• Reglan (metoclopramide) tablets, 10 mg: Take 2 tablets by mouth 3 times a day for 3 days.

• Zofran (ondansetron) tablets, 8 mg: Take 1 tablet by mouth every 8 hours for 3 days.

• Kytril (granisetron) tablets, 1 mg: Take 1 tablet by mouth twice a day.

• Anzemet (dolasetron) tablets, 100 mg: Take 1 tablet daily.

What To Do About Peripheral Neuropathy
Peripheral neuropathy refers to inflammation, injury or degeneration of the nerve cells. This may result from underlying conditions such as cancer, diabetes, infection, nutritional disorders, kidney disease and hypothyroidism. In cancer patients, peripheral neuropathy may occur due to the location of tumors or due to side effects of chemotherapy. Vincristine, Velban, cisplatin, Taxol, VP-16 and Navelbine are some of the drugs most commonly implicated.

Symptoms of peripheral neuropathy frequently include numbness and/or tingling in the hands and feet; loss of fine motor control; loss of sensation to temperature or vibration; unusual sensations such as electric or burning pain; abnormal gait; and loss of strength or weakened muscles. Any of these symptoms should be reported to your physician.

The nerves that control bowel and bladder function (the autonomic nervous system) may also be affected, resulting in constipation or difficulty urinating. Constipation should be treated with stool softeners and/or laxatives, as well as by increasing fiber and fluid intake. If you experience any difficulty urinating, your physician should be notified.

When sensation is altered, it becomes very important to evaluate your environment for safety. We would like to offer the following suggestions:

In the home

• Use care when cooking. Use potholders to handle pans and to remove pots from the oven. Avoid excessively hot water for dishwashing and wear rubber gloves. Be extra careful when using knives or handling glass that could be slippery. Use visual cues to increase safety when tactile sensation is decreased.

• Assistive devices are available to compensate for decreased muscle strength. These include zipper pulls, knob turners, writing grips, jar openers, easy lamp switches, long shoe horns, Velcro straps, and weighted utensils. Some of these are available from hardware stores; others can be obtained through an occupational therapist.

• Reduce the risk of injury in the bathroom. Install handrails in the shower or tub, or near the toilet. Use soap on a rope and safety bars in the tub or shower. Wet floors can be dangerous; outside the tub, bathmats with rubber backing are safer than those without. Bathtub thermometers are available to avoid scalding when sensation is decreased.

• Electric shavers are safer than razors.

• Wear gloves and socks when the temperature drops. Slippers should be worn, and should have rubber soles. If you have area rugs, make sure they have nonskid backing or are affixed to the floor to minimize the risk of tripping.

Around the home

• Clean up oil and other spills in the garage promptly.

• Keep hoses and tools off the floor where they could be tripped over. Hang up rakes and brooms.

• Wear gloves in the garden to avoid scratches and to keep dirt out of cuts. Use care when cutting anything in the yard.

• It is important to evaluate your ability to do certain tasks safely, especially when using any motorized equipment. Seek assistance for especially risky tasks such as mowing the lawn, climbing ladders, and carrying heavy objects. You should discuss the safety of driving a car with your physician if you have experienced a change in sensation or reflexes in your legs or feet.

Treatment Approaches
Medications are available that can reduce the discomfort of peripheral neuropathy. These include oral narcotics to relieve pain, as well as anticonvulsants and antidepressants, which act on nerve cells to relieve pain and other symptoms. Your physician will discuss the potential benefits of using these medicines with you.

Non-pharmacologic approaches include physical therapy for range of motion exercises, stretching, and massage.

Occupational therapists may be able to assist with orthotic devices, splints or canes.

Coping with peripheral neuropathy can be challenging. Often symptoms may be transient, though recovery may take a long time to achieve. In some cases, symptoms may be permanent. For these reasons, it is important step up an ongoing dialogue with your caregivers both at the doctor's office and at home to minimize the risk of injury and maximize comfort.

What To Do About Mouth Problems
Soreness and pain in the mouth is an uncomfortable, but usually temporary, side effect of chemotherapy. It occurs because chemotherapy affects cells in the body that reproduce themselves very rapidly, such as those in the bone marrow where blood cells are made, the hair follicles, and mucous membranes. Certain types of chemotherapy, such as 5FU, Adriamycin, and Methotrexate, are more likely to cause mouth problems, but other drugs can also be to blame.

You may experience general mouth tenderness and/or sores in the mouth. This may occur a few days or 1 to 2 weeks after chemotherapy. Mouth sores can lead to infections and can interfere with eating and drinking. Please call your physician or nurse if mouth problems develop.

The following tips may help you manage mouth problems

• Rinse your mouth 4 times a day with salt and soda mouthwash. Salt and baking soda (1/4 teaspoon of each) should be mixed in 8 ounces of warm water; swish, gargle and spit until the glass is used up. Some people like to make up a quart in the morning (use 1 teaspoon of salt and 1 teaspoon of soda) and leave it in the bathroom to use throughout the day.

• Take vitamin 86, 100 mg 2 times a day every day while you are receiving chemotherapy, in addition to your regular multivitamin. Vitamin 86 helps the tissues in your mouth to heal faster.

• Use a soft bristle toothbrush. If your gums bleed when you floss, avoid that until your mouth feels better. Remove dentures when not necessary for eating.

• Avoid alcohol-containing mouthwashes, which may be drying and irritating.

• Eat soft, bland foods at room temperature. Avoid hard crusty bread and citrus fruits, which may cut or sting your mouth.

• Over the counter topical anesthetics may temporarily numb any particularly sore spots.

• Consult your physician or nurse prior to dental work. Your dentist should be aware that you are receiving chemotherapy, and may prescribe antibiotics prior to performing any routine dental cleaning.

Call your Physician or nurse when -

• You have sores in your mouth or throat that prevent you from eating or drinking comfortably. You may require a prescription mouthwash to numb your mouth in order to eat more comfortably.

• You notice white patches on your tongue or the back of your throat. This may indicate a fungal infection that requires a prescription medicine to heal.

• You develop fever blisters on the outside of the lips or nostrils. You may feel tingling, burning, or swelling before the blister comes to the surface. Fever blisters are caused by the herpes virus, and usually heal on their own, but a prescription medication may help them to go away faster.

Some people develop mouth sores after the first cycle of chemotherapy and never again; other people have problems with each treatment. It is important to let your physician or nurse know when you have problems. Our goal is to minimize the risk of infection and to maximize your comfort.

What To Do When Your Blood Counts Are Low
Cancer cells grow and multiply rapidly, and chemotherapy specifically attacks rapidly growing cells. Healthy cells may also be affected by chemotherapy because they naturally reproduce faster than other cells in your body. Healthy cells that may be negatively affected by chemotherapy include those in the hair follicles, in the mucous membranes, and in the bone marrow where blood cells are made.

Prior to each cycle of chemotherapy, your physician will order a complete blood count (CBC) to make sure it is safe to administer your treatment. Blood counts begin to decrease after chemotherapy, and reach their low point, or nadir, 10 to 14 days after the first day of your treatment cycle. We will schedule an appointment for you at that point to check your counts and see how they have been affected by the chemotherapy.

We will specifically be looking at the following results:

White blood cells fight infection. Signs of infection include

• Fever (temperature over 100.4 F while not feeling well)

• Shaking chills

• Pain or burning when you urinate Diarrhea

• Sore throat

• Cough, with or without phlegm Cold or flu symptoms

• Skin rashes or sores

Notify your physician or nurse immediately if any symptoms of infection develop. A CBC will be checked and oral antibiotics may be prescribed. If the white blood count is especially low and signs of infection are present, your physician may decide to admit you to the hospital for intravenous antibiotics for a few days. We also may decide to prescribe oral antibiotics at your nadir visit even if you are feeling well, just to prevent the need for hospitalization for infection.

When the white blood count is low, avoid crowds and close contact with sick adults and children. Save dental work until after the white blood count improves. Prevent oral infections by reporting any sores in the mouth and following our guidelines for preventing mouth problems. Watch for rashes or sores on the skin. The single most important way to prevent infection is through frequent hand washing after contact with other people, before eating, and after using the bathroom.

In some cases, your physician may decide to prescribe a medication to raise the white blood count, called GCSF (also known as Neupogen), for injection at home. In those cases, a nurse will instruct you in how to do the injection, and will arrange to supply you with everything you need to take this medicine comfortably and safely.

Red blood cells carry oxygen to all the cells in your body. When the red blood count is low, you become anemic.

Signs of anemia include

• Difficulty catching your breath after activity

• Rapid heart rate

• Dizziness when standing up from a sitting or lying position

• Fatigue and weakness

• Pale mucous membranes

Some people are anemic when they begin their treatments due to underlying disease; others develop anemia over time due to the effects of chemotherapy. If symptoms of anemia develop, get plenty of rest, and take breaks between activities. Avoid dizziness by getting up slowly from a lying to ,a standing position. When we check your CBC in the office, we will monitor you for anemia. In some cases, your physician may decide to prescribe Procrit in order to raise your red blood count. Procrit is a medicine injected at home on a weekly basis. In these cases, a nurse will instruct you in how to do the injection, and will arrange to supply you with everything you need to do the injection safely and comfortably. In certain cases, a blood transfusion may be needed in order to treat your anemia rapidly.

Platelets help your blood to clot. Signs of a low platelet count include

• Nosebleeds

• Bleeding gums

• Easy bruising

• Blood in the urine (your urine may appear pink, tea-colored, red, or may contain clots)

• Rectal bleeding, especially from hemorrhoids

• Petichiae (pinpoint red spots on the skin, especially on the arms, shins and under the tongue)

• Prolonged bleeding from cuts

When the platelet count is low, avoid aspirin and aspirin-containing medications, such as those for cold/flu symptoms, since aspirin interferes with normal platelet function. Avoid flossing your teeth, and use a soft brush. Shave with an electric razor and be careful when using sharp tools and knives. Avoid contact sports, and always wear a helmet when bike riding or roller lading. Dental work should be delayed until the platelet count recovers. If a nosebleed develops, apply ice and pressure to the bridge of the nose until it stops. If any of the above signs of low platelet count develops, call your physician. A CBC will be checked and in certain cases, a platelet transfusion may be required when the count is extremely low.

The overall message in here is to call your physician or nurse if any of the above symptoms occur. Also call Uncontrolled nausea, blood in the urine, or with any questions you may have. We encourage frequent communication with the office, especially in the beginning when everything is strange and new. Feel free to use this outline as a guide, but not as a substitute for contact with the physician or nurse. During the day the oncology nurses are available by phone and voice mail, and a physician is available 24 hours a day and on weekends, through our main office phone number, (415) 923-3012.

What To Do About Hair Loss From Chemotherapy
One of the more upsetting side effects of chemotherapy is the temporary loss or thinning of hair. For many people, hair loss is the most tangible fact that they are receiving treatment for cancer; this period when hair loss begins is often very difficult emotionally.

Hair loss occurs because anti-cancer drugs affect rapidly growing cells in the body, including blood-producing cells in the bone marrow, mucous membranes, and hair follicles. The amount of hair loss depends on the type and dosage of chemotherapy you receive. You will begin to notice thinning of the hair around 2 to 3 weeks after starting chemotherapy. Hair on the head is usually affected the most, but body hair growth may also slow. Some people may lose eyelashes or eyebrows as well. Your scalp may feel sore at first, but this sensation usually resolves quickly.

Some tips to cope with hair loss include

• Use mild shampoos during chemotherapy. You may decide not to wash your hair as often as usual.

• Use a satin pillowcase to avoid hair tangling.

• Sleep with a stocking cap or a hair net when your hair begins to thin; this will help contain loose hairs. Cut your hair short at the beginning of treatment to make it easier to manage.

• Avoid chemical treatments that may further damage hair.

• Shop for a wig to match your hair color and style before hair loss begins.

• Contact the local branch of the American Cancer Society regarding free wigs.

• Ask your physician for a prescription for a “cranial head prosthesis” to submit to your insurance company for complete or partial reimbursement. A wig for cancer treatment is a tax-deductible medical expense.

Your hair will begin to grow back around 4 to 6 weeks after you finish chemotherapy. It may be a different texture and/or color when it regrows. Some people who normally have straight hair find that their hair grows back curly. You may have some gray hair when it grows back. The rate of regrowth should be similar to what it was before treatment began, usually 14 to Yi inch per month.

The Following Are Some Wig Suppliers In The Area That Our Clients Have Recommended

Your Personal Image
323 Geary Street, #319
San Francisco, CA 94102
415-421-8456

The Wig Palace
159 East 5th Avenue
San Mateo, CA 94401
650-347-6125

A Lady's Touch
(CPMC California Campus)
3698 California Street
San Francisco, CA 94118
415-454-6058 (San Rafael office)

Hansen Fontana
536 Bryant Street
San Francisco, CA 94107
415-495-8888

Continental Wig Salon and Boutique
1121 4th Street
San Rafael, CA 94901
415-454-0101

Peggy Tom - Personalized Haircare
323 Geary Street, #716
San Francisco, CA 94102
415-391-3008

Studio International
2850 22nd Street
San Francisco, CA 94110
415-641-9447

Information about Prescription Refills

When you need prescription refills, the following information may be helpful

• Please check the prescription label to see if you have additional refills prescribed. If so, you only need to call your pharmacy and request that the prescription be prepared for you. You do not need to call the office if there are additional refills allowed on the label.

• If there are no refills left on your prescription, you may either ask the pharmacy to contact us, or you may call us yourself and leave a message. It is helpful to have the bottle in front of you when you call so that we have the correct dosing information and the prescription number. Please be sure to let the receptionist know which physician prescribed your medicine.

• Allow enough time so that you don't run out of your medication prior to a weekend or a vacation.

• Certain medications may require prior authorization from your insurance company. If so, the pharmacist will tell you and we will need to contact the insurance company before you can fill the prescription. This process may take an extra day, so plan accordingly.

• Prescriptions for narcotic pain medicines often need to be filled with a written prescription called a triplicate. Triplicates are only valid for one week from the day they are written, so they cannot be requested far in advance. Because these medicines are so critical, it is important that you not run out, especially before the weekend. Please contact your physician a few days in advance and let us know when you will be picking the triplicate up so that we can have it ready in time.

• If you fill your prescriptions through a mail order pharmacy, be sure to let us know that you need a written prescription to send in with your co-payment. Some companies allow a 90-day supply, and others only a 1-month supply. Please let us know what you need when you request the written prescription.

We are happy to provide prescriptions for you that pertain to your treatment here. However, we believe it is important to maintain your relationship with your primary physician, and therefore, cannot refill prescriptions written by other providers.

What To Do About Constipation
Constipation is an unpleasant symptom that may affect people for various reasons at times in their lives. We define constipation as difficulty passing bowel movements, rather than as failure to have a bowel movement within a specified number of days. Most people have a regular pattern, and this varies for each individual. In general, it is easier to prevent constipation than to treat it. Our goal is to keep your bowel movements regular and to avoid prolonged constipation, which might lead to fecal impaction.

Factors that tend to make people constipated include diets low in fiber, dehydration, lack of exercise, and narcotic pain medication. Additionally, some chemotherapy medicines, such as vincristine, Velban, cisplatin, VP-16 and Navelbine, may cause constipation. You can maintain regular bowel habits by increasing your intake of whole grains, fruits and vegetables, and fluids of any type that appeal to you. Maintaining a minimal degree of activity is also important.

If your doctor has prescribed a narcotic pain medication, constipation is a predictable side effect, but one which can be managed by you and your caregivers. Frequently, we will recommend a stool softener and/or laxative at the time you begin using these medicines. The following are some over-the-counter (OTC) remedies that you may find helpful. We recommend you start using these when you begin taking pain medicines on a regular basis.

• Senokot or Senokot-Sis a natural vegetable derivative that works very well to counter the constipation caused by narcotics. Generally we recommend that you take 1 tablet twice a day to start, but this may need to be increased up to 2 tablets 4 times a day if needed. Senokot-S 'contains a stool softener, so if you take this, you do not necessarily need to add the next medicine.

• Docusate Sodium (also known as Colace or DSS) helps your stool stay soft by increasing its water content. It is available in 100 mg or 250 mg strengths, and is generally taken twice a day. Again, this may need to be increased at times.

• If you find that you are still constipated despite regular use of the above medicines, you may add one of the following OTC laxatives. These work by increasing the muscular action of your intestines, and may cause temporary abdominal cramps, which usually subside after you have a bowel movement.

• Milk of Magnesia is usually taken at bedtime and works by the following morning. The dose is 2 tablespoons and may be repeated every 8 hours as needed.

• Bisacodyl (also known as Dulcolax)is available in pill or suppository form. Both forms work fairly rapidly. If you use the pills, take 1 or 2 at bedtime. If you prefer the suppository, use 1 rectally; this usually results in a bowel movement within 1 hour.

• Magnesium Citrate (also known as Citroma)is a clear carbonated liquid that may be helpful if the above medications do not work. Generally people begin by drinking Y4 to V2 a bottle, which should work in about 6 hours.

• The above remedies are meant to be guidelines for you, and should prove helpful in countering the constipation resulting from narcotics. If you use these and are still constipated, consult your nurse or physician before making changes. There are also additional prescription medications that may be helpful for you.

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