Despite the many advances in cancer treatments at major cancer centers, the answer to this question can be ‘no’.  You should consider traveling far away to get chemotherapy or radiation therapy when there is a clinical trial you would like to participate in.  Consider the marginal benefit and how innovative the treatment is at a center far away.  In the case of having surgery, traveling far to get an experienced surgeon makes sense if there is not one close to home.  But if the chemo or radiation you would be get at a hospital far away is the same chemo or radiation you would get close to home (i.e. same medication, same dose, same length… or at least very similar), then consider enjoying the comfort of home.

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.

Expert Analysis Highlights:

• For repeated injections and blood drawing during cancer treatment, you will likely need to have an implantable device for gaining access to your central veins
• Veins in the arms are usually used on a short-term basis, but they may be difficult, or even painful, to stick into repeatedly
• A range of products give access to the larger veins without causing pain from repeated injections or damage to these veins
• CR Bard Company has a nice website for patients who are being considered for an implantable device

The video segment here shows how a pediatric patient can have his chemotherapy administered without much discomfort, and without risking damage to his veins due to repeated injections. Whether you are an adult or a child with cancer requiring repeated injection or infusion of drugs, you will likely need to have an implantable device for gaining access to your central veins.

Why? Because administering drugs or other agents by intravenous infusion over a long period, or drawing repeated blood samples, can be a painful and difficult ordeal for patients and the healthcare team, especially when the patient is a child. Veins in the arms are usually used on a short-term basis, but they may be difficult, or even painful, to stick into repeatedly. The veins can dry up (thrombosis) or even get inflamed or infected (thrombophlebitis). Even more difficult and painful is resorting to getting blood, or giving infusions, from veins in the neck or the legs. This is a last resort when the veins in the arms have “given out”. We also know that it’s not just the needle and sometimes the drugs themselves can cause damage to the vein.  So-called “sclerotic agents”, such as adriamycin, can cause damage to the veins and infiltrate into the surrounding tissues, causing great tissue damage.

One of the significant technical advances for the cancer patients is the range of products that give doctors and nurses access to the larger veins without causing pain from repeated injections or damage to these veins.  Your doctor will go over with you about the different kinds of venous access to a major vein going to the heart. In each circumstance, it involves some minor surgery to put these catheters in place. These options are an implantable (subcutaneous) port, an , or a peripherally inserted central catheter (PICC).

The CR Bard Company has a nice website for patients who are being considered for an implantable port. They also have some great booklets for children (in English and Spanish) that describe these catheters which can help the kids understand the process with clearer expectations of how they are used during treatment. As described in the booklet to parents: “By maintaining a matter-of-fact and positive attitude, you can help your child adjust favorably to his … [central line, implantable port, PICC line].” If you or a loved one is facing this procedure, talk to your doctor about the options that would be most appropriate in your circumstance.

I highly recommend these books for children to help describe and explain catheters:

For a children’s book about the implantable venous port, go to: http://www.bardaccess.com/pdfs/other/MC-0406-00_A_Port_For_Me_web.pdf

For a children’s book about the central venous catheter, go to: http://www.bardaccess.com/pdfs/other/MC-0404-00_My_Central_Line_Book_web.pdf

For a children’s book about the peripherally inserted central catheter, go to: http://www.bardaccess.com/pdfs/other/MC-0405-00_My_PICC_Line_web.pdf

Expert Analysis Highlights:

• The decision-making for cancers of the rectum can be more complex than any other cancer
• Decisions about the initial treatment are often very complicated and require the treatment plan and care by oncologists of different specialties including surgery, medical oncology, and radiation oncology
• The patient has an important role in the treatment plan because their perception of “quality of life ” is important in deciding the extent of operation that they will accept
• Below are 12 important questions that you will need to go over with your doctors to determine the right treatment plan

The list of questions below should make it clear that the management of rectal cancer is very complex and should be performed by doctors who are very experienced and specialized in the treatment of these specific types of cancer. It is a real challenge for the doctors and for the patient to determine the right treatment that removes the cancer while preserving the function of surrounding organs and minimizing the number of complications that can be very debilitating after the treatment.

Here are 12 important questions that you will need to go over with your doctors:
1. What is the best way to stage the extent of the rectal cancer and, in addition, assess any spread to regional lymph glands or distant sites? Endoscopic ultrasound or MRI are the standard to assess the depth of invasion into the rectal wall and lymph nodes. CT scans for the liver and lungs.
2. Which type of surgical specialty should do my surgery (surgical oncologist, general surgeon, or colorectal surgeon)?
3. For the surgeon, how many operations for rectal cancer do you do each year? Should be a minimum of 12 per year.
4. Can the rectum be removed while sparing the anus so that a permanent colostomy is not necessary? Again, for the surgeon, are you trained to do “intersphincteric resections”, and how many have you done?
5. Should I have “minimally invasive” surgery, such as laparoscopic surgery or robotic surgery? Whereas minimally invasive approaches to colon cancer have been found to be as “safe” as an open operation, the same is yet to be determined for rectal cancer. The studies are ongoing. Minimally invasive approaches to rectal cancer is very new and should only be done as part of a clinical trial by surgeons with experience with minimally invasive procedures for the rectum.
6. If the cancer is small and does not invade very far into the rectal wall, is it possible to have a local excision only? (Be very careful with this! There is a lot of controversy over local excision. Local excision has a higher chance of recurring!)
7. Should chemotherapy and/or radiation therapy be given prior to surgery?
8. How much of adjacent pelvic organs need to be sacrificed in order to adequately treat the cancer?
9. Should molecular markers be obtained to help determine the type of chemotherapy which should be given?
10. What would be the side effects of radiation therapy to the pelvis and anus?
11. What are the long-term side effects of these complex treatments with regard to anal sphincter function (i.e. incontinence of stool or soiling) urination, fertility, and sexual function?
12. Do I have distant disease, or spread of cancer to the liver or lungs? If so, should I have systemic chemotherapy prior to an operation on the rectum? If you do have spread to the liver, make sure you are evaluated immediately by a surgeon who has significant experience with liver surgery, and especially liver surgery for colon or rectal cancer which has spread to the liver. These surgeons are usually found at a tertiary care facility or academic medical center. See a liver surgeon before starting chemotherapy!

When cancers of the rectum first present, the decisions about the initial treatment are often very complicated and require the treatment plan and care by oncologists of different specialties including surgery, medical oncology, and radiation oncology. In fact, the decision-making for cancers of the rectum can be more complex than any other cancer. The patient has an important role in the treatment plan because their perception of “quality of life ” is important in deciding the extent of operation that they will accept. Other factors that have a major role include:

• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs
• Spread of cancer to lymph nodes
• Spread of cancer to distant organs, like the liver or lungs,
• Distance of the lower end of the cancer from the anal sphincter muscles, and
• Size of the pelvis (men have a smaller and narrower pelvis than women)

Doctors usually make a distinction between the rectum and colon even though they are both part of the large bowel or intestine. In general, the rectum is the end of the large bowel and is situated inside the pelvis. The colon makes up the majority of the large bowel, which is located outside the pelvis. Given the anatomical differences between the colon and rectum, the treatment of their respective cancers is also different.

Cancers of the colon, which occur outside the pelvis, can grow to a large size but usually do not invade surrounding organs. The surgery is fairly straightforward and the surgical excision can take a wide margin or berth of normal tissue, including lymph nodes, without causing many side effects. By taking a margin of normal tissue, the surgeon can assure that all tumor is removed, including any disease that is microscopic. Depending on the pathology, which is determined after the colon cancer is removed, chemotherapy may be given after the operation.

In contrast, cancer arising in the rectum is growing in a small space confined by the pelvic bones, surrounded by organs such as the bladder, prostate in men or the uterus or vagina in women. Cancers growing low in the rectum can be especially difficult because they may be close to the anal sphincter muscles, which make it difficult to get an adequate margin of normal tissue. If the cancer is too low, the anus and anal sphincters may have to be removed as well in order to safely remove all the cancer and reduce the chance of having a recurrence. If the anus and anal sphincter muscles are removed, a permanent colostomy is required, whereby the end of the colon is brought out through the lower abdominal wall and attached to the skin to create a new channel for feces to leave the body into a colostomy bag.

Chemotherapy and radiation therapy may be given prior to an operation depending on:

• Distance of the tumor from the anus
• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs, or
• Spread of cancer to the surrounding lymph nodes

Chemotherapy and radiation given before the operation may shrink the tumor enough to allow an operation to save the sphincter muscles. In addition, chemoradiation therapy before an operation has been found to be more tolerable than after an operation and reduce the risk of having a recurrence in the pelvis. There are procedures (i.e. intersphincteric resection) that can be done to save the sphincter muscles as well, but these are not safe in every situation and are technically very challenging. These are specialized procedures and should only be done by surgeons with experience using these techniques.

Remember, an informed and educated patient will usually get better care and have a treatment that best fits their risk tolerance to the different types of treatment side effects and recurrence rates.

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

Capecitabine (XELODA, Roche) is the first FDA-approved oral chemotherapy for the treatment of both metastatic breast and colorectal cancers. The drug is approved for use in colorectal cancer, both as adjuvant therapy (i.e. drugs that modify the effect of other drugs) after surgery for Stage III (Dukes C) cancer and more metastatic colon cancer (Stage IV). Its use in breast cancer has been limited to metastatic breast cancer after primary drugs have failed (e.g.: docetaxel or paclitaxel).

In this video, Dr. Hyman Muss from the University of Vermont, discusses the results of a major clinical trial evaluated the oral agent capecitabine as the initial therapy compared to standard chemotherapy in women over age 65 with early-stage breast cancer. The logic is that Xeloda has been shown to be generally tolerated well by patients, especially in the older age group.

The results in over 600 elderly patients showed that standard intravenous chemotherapy gave better survival results than oral capecitabine alone. Dr Muss discusses the current state of using this drug in breast cancer patients. Details of the study, with Dr Muss as the lead author, are published in the May 14,2009 issue of the New England Journal of Medicine (vol360; pages 2055-65)