Family support is an important part of your cancer care, and when a recommended chemo or radiation regimen is one that you can have close to home, many oncologists will suggest having it done at a cancer center close to your family and support network.   Chemo and radiation can require frequent trips to the hospital (sometimes as many as 3-5 appointments per week).  In addition these treatments can sometimes be tiring.  Family and friend support can be helpful and sometimes critical.  This includes everything from rides to the hospital to verbal encouragement.  When getting a second opinion at a major cancer center far away from home, ask the oncologist if the recommended chemo or radiation regimen is the same or similar to what you can get closer to home.  Most importantly, consider the importance of your support network.

Hot flashes can be a very debilitating condition for women who undergo estrogen depletion, either naturally (with menopause), with surgical ablation (of the ovaries), with certain types of chemotherapy, or with pelvic radiation, any of which can induce sterilization.  For many women, hot flashes are a tolerable condition, even though it has great “nuisance value”. For others, the symptoms are much more severe and can be quite debilitating.  Of course, estrogen or progesterone replacement are “natural therapies”, but there are known risks of taking estrogen for a prolonged period of time.  And some women are still symptomatic with estrogen replacement therapy, except in high doses.

A new study has identified yet another drug for hot flashes.  This trial was conducted by Dr. Charles Loprinzi and colleagues from the Mayo Clinic in Rochester, MN (see video) who found that a commonly used neurology drug can significantly reduce the frequency and intensity of hot flashes. A substantial number of these women had a history of breast cancer and many of them were taking various anti-estrogen hormone therapies for their breast cancer.  In this trial, a total of 207 women were enrolled into the trial because they had “bothersome hot flashes,” as defined by occurrence at least 28 times per week and sufficient severity to make the patient desire therapeutic intervention.

Two doses of Lyrica (Pfizer, NY, NY) were administered (75 mg twice a day, or 150 mg twice a day) compared to a placebo (sugar pill). The investigators found that Lyrica decreased hot flashes and was reasonably well tolerated. The lower dose was recommended (75 mg twice daily) and its effects were roughly comparable to those previously reported with other drugs. The higher dose of Lyrica (150 mg twice daily) had significantly more toxicity than the placebo and was primarily associated with symptoms of dizziness, mental confusion and memory disturbances.

Compared to base-line, the frequency of hot flashes was reduced by 58.5% with the lower dose of Lyrica, and 61% with the higher dose.  Interestingly, there was a 36% reduction in the frequency of hot flashes for women were on the placebo! (This emphasizes the need for such control trials when the end points of the trial are symptom relief.)

This is a very nice clinical trial with a convincing result that adds another tolerable and safe drug to the list of those that physicians can use for treating severe hot flashes. There have been a number of other drugs that provide a 50% or greater reduction in hot flash frequency or severity. A partial list of those prescription drugs approved for use in treating hot flashes include:

1. Gabapentin (Gabarone, Pfizer, NY, NY)
2. Venlafaxine (Effexor, Wyeth Laboratories, Pfizer, NY, NY)
3. Desvenlafaxine (Pristiq, Wyeth Laboratories, Pfizer, NY, NY)
4. Fluxotine (Prozac, Lilly, Indianapolis, Indiana)
5. Citalopram (Celexa, Forest Laboratories, NY, NY)
6. Sertraline (Zoloft, Pfizer, New York, New York)
7. Paroxetine (Paxil, GlaxoSmithKline, Philadelphia, PA)
8. Estrogen (Premarin, Wyeth Laboratories, Pfizer, NY, NY)

Here’s more information about hot flashes from our companion website, patientresource.net:

A hot flash is a sudden, intense hot feeling on your face and sometimes upper body. A rapid heartbeat, nausea, dizziness, headache, weakness, and/or sweating may also occur at the same time. A “flush” follows the hot flash; during a flush, you become red and perspire. Hot flashes are perhaps the menopausal symptom that women find the most uncomfortable and inconvenient.

Among the general population of women, hot flashes may last for a year or two after menstrual periods have stopped or may persist for several years. The intensity of hot flashes caused by tamoxifen usually improves after the first 3-6 months of treatment. Hot flashes vary in duration and frequency; most episodes last a few minutes, and they often occur at night, with night sweats often waking up women in the middle of the night.

Hot flashes may have specific triggers. These triggers vary among women, but the most common ones include alcohol, caffeine, spicy food, stress, hot weather, hot showers, and saunas. Identifying and avoiding triggers can help decrease the frequency of hot flashes.

Some suggestions for coping with hot flashes include the following.

* Wear cotton and avoid wool and synthetic materials.
* Dress in layers, so you can remove clothes in layers if needed.
* Keep ice water nearby to drink when a hot flash begins.
* Wear cotton pajamas or a nightgown and use cotton sheets on the bed.
* Take a cool shower before going to bed.
* Open the refrigerator door and put your head in when a hot flash begins.

Some studies have shown that vitamin E or vitamin B6 supplements can help reduce hot flashes. If hot flashes are severe, your doctor may suggest a low dose of an antidepressant. The drug that has been shown to be most effective is venlafaxine (Effexor); paroxetine (Paxil) is another alternative and may be better tolerated by some women. Mild sedatives may also be of benefit but there are risks associated with their use.

Many menopausal women have turned to herbal remedies, such as ginseng, black cohosh, evening primrose oil, licorice root, and others to alleviate hot flashes. However, the safety of these remedies in women with breast cancer has not been determined. Do not take any herbal supplements without talking to your doctor first.

This is an amazing story and an inspiration to all cancer patients! See below for news about a mother who had the foresight to preserve the sperm of her teenage son who was being treated for leukemia…no doubt something that was not on the radar screen of a young person who has been given a diagnosis of a serious and life-threatening cancer. Most cancer patients first think about surviving their cancer, and only later on think about the consequences of treatment and cancer survivorship. The teenage boy benefited from the miracle of modern day chemotherapy, which is now pretty standard for most forms of leukemia and lymphoma affected children, teenagers, and young adults. As a consequence, he became sterile and could no longer have children.

Dial forward 22 years after the diagnosis of leukemia and you have a grown man who is married and wants to have children. Thanks to his mom, he was able to do this…on the first pass of in vitro fertilization no less!  This story demonstrates that there is no “shelf life” for appropriately preserved sperm or eggs. They can be frozen for 22 years and then literally brought back to life again!

See my blog on fertility issues in women with the same inspiring results:
“Fertility Preservation: An Issue Less Than Half of Affected Cancer Patients Are Told About”

The common factor about these stories is that the patients, their family, and their doctors were all supportive of these fertility issues and made appropriate arrangements so that these cancer survivors could have the benefit of being parents with children of their own genetic make-up! Unfortunately, the majority of studies show that less than half of eligible cancer patients actually receive this information and thus are rendered infertile (sterile) for the remainder of their life. So be sure to talk to ask your doctor about fertility issues!

See the news article below for more details.

From The London Times, April 14, 2009

A former leukaemia patient who had his sperm frozen as a teenager has fathered a baby after doctors successfully thawed his sample a record 22 years later.

Chris Biblis was 16 when doctors told him that he needed radiotherapy that would leave him sterile and recommended before going ahead with the life-saving treatment that they put a sample of his sperm into cryogenic storage for future use.

Now aged 38, he is celebrating the birth of a healthy baby daughter, Stella, who was conceived after scientists injected a defrosted sperm into an egg from his wife, Melodie, and implanted it in her uterus.

The 22-year lapse between storage in April 1986 and conception in June 2008 is a world record, according to specialists at the US fertility clinic who carried out the procedure.

“From my life being saved to being able to create a life, words just can’t describe where we are now,” said Mr Biblis, of Charlotte, North Carolina, who has been free of leukaemia since the age of 18.

“I’ve got this bundle of joy to appreciate. It’s truly a miracle,” he told ABC News.

The case is being hailed as an illustration of how far infertility treatment has advanced in the past two decades and proof that sperm can remain viable for decades if they are preserved in liquid nitrogen. The previous record was 21 years.

The procedure used to create Stella did not even exist when Mr Biblis gave the sample in 1986 during his six-year struggle against leukaemia.

“I was trying to get through high school and, you know, living one day at a time just hoping I was going to make it,” he said.

It was not until 1992 that the method of intracytoplasmic sperm injection (ICSI) – by which scientists carefully select a healthy sperm cell and insert it into an egg in the laboratory – was successfully pioneered.

The technique carries an increased chance of conception beyond conventional IVF procedures, in which sperm and eggs are mixed in the laboratory to fertilise spontaneously, and was used because only 35 per cent of Mr Biblis’s sperm cells were deemed viable after thawing.

Doctors selected the best of the remaining cells and injected them into ten eggs harvested from Mrs Biblis, of which seven fertilised successfully in the laboratory. Two of the embryos were implanted, though only one survived, and five remain in storage, allowing the couple the option of having more children.

“They achieved pregnancy on their first cycle of ICSI . . . We had every reason to expect a perfect baby but are thrilled nonetheless,” said Richard Wing, a fertility specialist and founder of Reproductive Endocrinology Associates of Charlotte: “I had no concern about working with old sperm – bovine and equine sperm has been frozen for long periods and has resulted in successful gestations.”

Fertility is an important quality of life issue for cancer patients of child-bearing age. Some types of cancer treatments (especially certain forms of chemotherapy and with radiation to the pelvis) can impair fertility. Such patients may benefit from referral to a reproduction specialist before they start their cancer treatment. Unfortunately, the majority of studies show that less than half of eligible cancer patients actually receive this information and thus are rendered infertile (sterile) for the remainder of their life. One can understand that at the onset of a cancer diagnosis that the primary focus is on a life-threatening situation. The dilemma comes later, when patients are actually enjoying a long-term life and these survivorship issues then become paramount.

Many cancer patients interested in fertility preservation prefer to have biological children rather than adopt or use third party reproduction. Studies of cancer patients report that loss of fertility is of immense concern that can cause great distress. The American Society of Clinical Oncology (ASCO) and the American Society for Reproductive Medicine (ASRM) have developed guidelines on this issue. These guidelines suggest that oncologists “should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists”.  Addressing this issue with patients is an important aspect of quality cancer care.

With advances in reproductive biology and technology, fertility preservation methods are now available that allow some cancer patients to preserve fertility before treatment. Sperm cryopreservation is the primary option available to males and has high likelihood of success. For women, fertility preservation issues are more complex. Embryo cryopreservation is the most established option, which involves fertilization of egg with sperm through in vitro fertilization. Egg freezing, an experimental option, is typically used in women who do not have a partner or do not wish to use a donor sperm.

In a recent article published in the Journal of Clinical Oncology (JCO, volume 27: [page 5952, 2009), Dr. Guinn and colleagues conducted a national study about fertility preservation and physician attitudes. Forty-seven percent of 516 physician respondents routinely refer their cancer patients of child-bearing age to a reproductive specialist. Referrals were more likely when patients routinely asked about fertility preservation, and also when among female physicians and those with a favorable attitude towards fertility preservation. On the other hand, half of the physicians are not referring patients.

Not all drugs cause problems with ovulation or sperm viability… others do. Discuss it with your doctor. Remember that radiation to the pelvis may also result in sterility (but not if radiation is given to other parts of the body). If you are interested in pursuing this, ask your doctor to refer you to a reproductive specialist. Studies have found that banking sperm or embryos was viewed as a positive factor to help patients cope with their disease, even if they never used them in the future.

The most important message for those of you reading this blog who are of child-bearing age… or who are a partner or care-giver of a cancer patient of child-bearing age: please discuss fertility options with your oncologist!

For more information, go to our companion website www.patientresource.net.

This is an Oncology Podcast segment for women about preparing for hair loss and how to cover the head with wigs and scarves.

Here’s more information from our companion website, patientresource.net:

Hair loss from chemotherapy usually begins within 10-14 days after the start of treatment and gets worse within 1 to 2 months. In some instances, depending on the chemotherapy drugs, hair loss may begin with a sensation of the scalp itching, and within a few hours hair begins to fall out. Hair loss typically continues throughout treatment. Hair usually begins to grow back 4-6 weeks after the end of treatment. In general, hair grows back at a rate of about one-quarter inch per month.

It takes longer for hair to be lost during radiation therapy. Hair loss in the area being treated usually begins 2-3 weeks after the first treatment. All hair in that area falls out within about 1 week and may begin to regrow 3-6 months after treatment has ended. However, the hair loss may be permanent.

There are no effective ways to prevent the loss of hair during cancer treatment. Being gentle with your hair may help make your hair loss more gradual and improve the regrowth of your hair.

The best way to manage hair loss (medical term is alopecia) is to think about what will make you feel most comfortable with your appearance. Most people with cancer have found that it is easier to make that decision before treatment starts. Many women choose to wear a wig, but some women find wigs to be irritating or itchy. If you decide to get a wig, consider several factors.

Tips on Wigs
* Buy the wig before treatment begins or at the beginning of treatment — you can better match your hair color and texture
* Try on several different wigs to find one that you really like
* Consider buying two wigs, one for everyday use and one for special occasions
* If you can’t afford a custom wig, buy a standard (less expensive) wig and have it professionally styled
* Ask if the wig can be adjusted — your wig size can shrink as you lose hair
* Get a prescription from your doctor for the wig because it is often covered by health insurance (Prescription must state “skull prosthesis for hair loss caused by cancer treatment”)
* Contact your local branch of the American Cancer Society to learn about free wigs that have been donated by patients after they have completed treatment

Wearing a scarf, hat, or other type of head covering is also a choice. Your scalp may be tender from treatment (especially radiation therapy to the head), and a head covering can protect your scalp against cold and sunlight. If you do not wear a head covering, make sure to use sunscreen on your scalp when you will be outside.

Some people choose to cut their hair short so that hair loss will not be as traumatic when it falls out. Others shave their head completely before treatment begins. How you handle hair loss is a personal decision and the right choice is the one that makes you feel most comfortable.

Being Gentle To Your Hair
* Use a soft-bristle brush and/or a wide-toothed comb
* Wash hair with a gentle, pH-balanced shampoo (avoid shampoos with strong detergents, chemicals, or frangrances)
* Do not use hair dryers, hot rollers, or curling irons
* Do not bleach or color your hair or get a permanent
* Avoid hair sytles that pull on the hair, such as braids or ponytails
* Sleep on a satin pillow case or put a hair net on to decrease friction

There are a number of resources that provide wigs and related products. The following is list of retailers provided by the American Cancer Society:

ChemoSavvy
PO Box 175
Green Mountain Falls, CO 80819
Toll-free number: 1-888-599-3560
Web site: www.chemosavvy.com
This company supplies wigs, hats, scarves, turbans, and accessories for women and children to consumers.

Doma Designs
426 East Bissell Avenue
Oil City, PA 16301
Toll-free number: 1-888-603-1206
Web site: www.domadesigns.com
This company supplies hats, bandanas, and accessories for women, men, and children to consumers.

Headcovers Unlimited
2020-C Anders Lane
Kemah, TX 77565
Toll-free number: 1-800-264-HATS (4287)
Web site: www.headcovers.com
This company supplies wigs, turbans, hats, and accessories for women, men, and children to consumers.

Look of Love International
1795-B Route 27 South
Edison, NJ 08817
Toll-free number: 1-800-526-7627
Web site: www.lookoflove.com
This company supplies wigs and accessories to consumers.

“tlc” Tender Loving Care®
PO Box 395
Louisiana, MO 63353-0395
Toll-free number: 1-800-850-9445
Web Site: www.tlcdirect.org
This company supplies wigs, hats, turbans, breast prostheses, bras, and other products to consumers. “tlc” is a part of ACS Products, Inc., an affiliate of the American Cancer Society.

Yako Corp DBA Hai’s Wigs
6474 Lake Worth Road
Lake Worth, FL 33463
Toll-free number: 1-888-471-2659
Web Site: www.ladywig.com
This is an online retailer that also has a physical store selling wigs and hair accessories. This company specializes in treatment-related hair loss.

Tender Loving Care®
PO Box 395
Louisiana, MO 63353-0395
Toll-free number: 1-800-850-9445
Web Site: www.tlcdirect.org
This company supplies breast prostheses, bras, wigs, hats, turbans, and other products to consumers. “tlc” is a part of ACS Products, Inc., an affiliate of the American Cancer Society

Bone marrow stimulating drugs are beneficial in some cancer treatment circumstances, but dangerous in others. A group of drugs, Aranesp, Epogen, and Procrit, have been a vital component of cancer chemotherapy management for many years. Clearly, this class of drugs (called erythropoiesis-stimulating agents) are a critical component of symptom management that allows cancer drugs to be given at higher, more therapeutic doses. Indeed, they have enabled oncologists to give a greater therapeutic dose of chemotherapy than was previously possible because the bone marrow cells (which produce white blood cells, red blood cells and platelets) could be wiped out without these drugs resulting in serious anemia, infections, and other side effects.

In 2007 and again in 2008, the FDA issued a “Black Box” warning on these drugs because of specific circumstances of serious adverse events identified from clinical trials. These are very potent drugs, and if not administered according to the FDA-approved labeling information, could themselves cause serious and life-threatening side effects and/or death (quotes from the FDA reports). They are the proverbial “two-edged sword that have benefit on the one hand and dangers on the other.

As new information has emerged from clinical trials, the FDA has made modifications in the indications for using the drugs and monitoring their effects. They recommend that doctors use the lowest possible dose to slowly raise the hemoglobin level (as a measure of anemia) to the lowest level that would avoid the need for blood transfusions. On the other hand, they are powerful drugs themselves and recent evidence from clinical trials have shown that they can have an adverse effect in some patient settings, including an actual reductions of survival rates in certain types of cancer patients if given too long or in too high a dose. They should not be used more aggressively to raise hemoglobin levels to a normal level. Moreover, they are not beneficial for cancer patients who are not getting chemotherapy.

Readers of this blog who want more extended and specific information can go to several websites. The most recent information from the FDA was posted May, 2009 (see their website:http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm109375.htm). Also, the Centocor Ortho Biotech website has a lot of educational information, in language approved by the FDA, for these three drugs at http://www.procrit.com.

There is yet another drug called Neulasta (pegfilgrastim) that is prescribed to reduce the risk of infection (initially marked by fever) in patients with some tumors receiving strong chemotherapy that decreases the number of infection-fighting white blood cells. While it also has some potentially dangerous side effects, it does not have the “black box” warnings of the three drugs listed above. For more information, see their website at http://www.neulasta.com.

If you have questions about these drugs, be sure to ask your doctor!

Senator Arlen Specter (D-PA) gives a lighthearted interview about his experience with chemotherapy for lymphoma and the inconvenience of temporarily being bald! Here’s more information from our companion website, patientresource.net:

Hair loss from chemotherapy usually begins within 10-14 days after the start of treatment and gets worse within 1 to 2 months. In some instances, depending on the chemotherapy drugs, hair loss may begin with a sensation of the scalp itching, and within a few hours hair begins to fall out. Hair loss typically continues throughout treatment. Hair usually begins to grow back 4-6 weeks after the end of treatment. In general, hair grows back at a rate of about one-quarter inch per month.

It takes longer for hair to be lost during radiation therapy. Hair loss in the area being treated usually begins 2-3 weeks after the first treatment. All hair in that area falls out within about 1 week and may begin to regrow 3-6 months after treatment has ended. However, the hair loss may be permanent.

There are no effective ways to prevent the loss of hair during cancer treatment. Being gentle with your hair may help make your hair loss more gradual and improve the regrowth of your hair.

The best way to manage alopecia is to think about what will make you feel most comfortable with your appearance. Most people with cancer have found that it is easier to make that decision before treatment starts. Many women choose to wear a wig, but some women find wigs to be irritating or itchy. If you decide to get a wig, consider several factors.

Wearing a scarf, hat, or other type of head covering is also a choice. Your scalp may be tender from treatment (especially radiation therapy to the head), and a head covering can protect your scalp against cold and sunlight. If you do not wear a head covering, make sure to use sunscreen on your scalp when you will be outside.

Some people choose to cut their hair short so that hair loss will not be as traumatic when it falls out. Others shave their head completely before treatment begins. How you handle hair loss is a personal decision and the right choice is the one that makes you feel most comfortable.

Being Gentle To Your Hair

* Use a soft-bristle brush and/or a wide-toothed comb
* Wash hair with a gentle, pH-balanced shampoo (avoid shampoos with strong detergents, chemicals, or frangrances)
* Do not use hair dryers, hot rollers, or curling irons
* Do not bleach or color your hair or get a permanent
* Avoid hair sytles that pull on the hair, such as braids or ponytails
* Sleep on a satin pillow case or put a hair net on to decrease friction

Tips on Wigs

* Buy the wig before treatment begins or at the beginning of treatment — you can better match your hair color and texture
* Try on several different wigs to find one that you really like
* Consider buying two wigs, one for everyday use and one for special occasions
* If you can’t afford a custom wig, buy a standard (less expensive) wig and have it professionally styled
* Ask if the wig can be adjusted — your wig size can shrink as you lose hair
* Get a prescription from your doctor for the wig because it is often covered by health insurance (Prescription must state “skull prosthesis for hair loss caused by cancer treatment”)
* Contact your local branch of the American Cancer Society to learn about free wigs that have been donated by patients after they have completed treatment