Expert Analysis Highlights:

• Clinical trials serve two purposes: Offering patients the newest treatment options and advancing scientific knowledge for future patients
• Below are some useful questions you should ask when deciding whether or not to participate in a clinical trial
• To find out if there is a trial in the area you need treatment, check out clinicaltrials.gov where all trials are registered
• For more information about clinical trials, click on the following link to patientresource.net

The phrase “Clinical Trials” means one of two things to most people: An opportunity to get the latest and greatest new treatment, or a futile human experiment with no major benefit to them.  The truth is somewhere in between.  The bottom line is that it depends on the trial and its design.

To review, a clinical trial is a program offered by some hospitals which assigns you randomly to receive standard treatment or a new treatment for which the potential benefit is not yet proven.  Some trials have 3 “arms” or treatment paths.  The key to a good research study from a design standpoint is that patients are randomly assigned to a treatment path and then the outcomes are compared.  This is the most scientifically valid way of assessing how good the treatments work.

Here are some useful questions you should ask when deciding whether or not to participate in a clinical trial:

• What is the benefit seen in previous studies of the new treatment being studied in the trial?
• Does the new treatment being studied work by a different mechanism (i.e. a novel treatment) compared to the standard treatment?
• Where did the idea for the clinical trial come from?
• What are the quality of life and survival differences likely if I do not participate in the trial?

For some trials the new treatment may be very promising, while for other trials, the benefit may be marginal or even negligible based on prior studies.

For your protection, all clinical trials are governed by rules which hospitals are ethically and legally obliged to follow.  The rules are: 1) If the benefit of one of the treatment options is clearly apparent during the course of the study, the study must be ended early so that the results can be disseminated and patients do not have to continue a course of treatment which is known to be inferior, 2) You must be informed of every aspect of the design of the study, 3) You can opt out of the trial at any time, and 4) You are entitled to see the results of the study once completed.

Clinical trials serve two purposes: Offering patients the newest treatment options and advancing scientific knowledge for future patients.  Consider it not just a way of getting a new treatment, but also a way of helping inform future patients with a similar cancer.  In general, clinical trials provide hope for patients whose treatment options might otherwise be limited.  Many trials are managed on a multi-institution level, making the trials available on a local level for many patients.

To find out if there is a trial in the area you need treatment, check out clinical trials.gov where all trials are registered.  There you will be able to find out what the treatment arms are, whether the trial is open of closed to new patients, and where to go to see if you’re a candidate.

An ovarian cancer patient in England describes her difficult struggles with chronic pain due to her advancing disease and the side effects of her chemotherapy. In the video, Dr Beverly Collett, Immediate Past President of the British Pain Society describes a survey in Great Britain of advanced cancer patients who responded that about one-third had “intractable pain.” In other words, pain that just would not go away.

No one with cancer should be denied appropriate amounts of pain medicines, including narcotics if necessary (we are not worried about addiction here). Most major cancer centers have pain specialists who can be helpful consultants in this vital subject.

The National Cancer Institute has an informative web section on cancer pain control. Go to http://www.cancer.gov/cancertopics/paincontrol.

Also, a new website was recently launched to help cancer patients find pain relief: Cancer-pain.org.  Some of their website is still “under construction.” It has a very distinguished Advisory Board, including Diane Blum who is on our Patient Resource Cancer Guide Patient Advisory Board. Their news announcement is pasted below:

The Association of Cancer Online Resources (ACOR), the largest online community of cancer patients, announces the launch of a new website, Cancer-pain.org, to provide cancer patients with the education and support they need to obtain effective relief from pain.

“There is always a way to alleviate pain; however, effective treatment of cancer pain has been a problem long acknowledged by the cancer community,” said Gilles Frydman, President of ACOR. “A significant majority of cancer patients suffer pain as their disease progresses, but almost half do not get adequate pain relief. Cancer-pain.org is our commitment to help cancer patients better understand their pain and obtain more effective pain control.” Cancer-pain.org features sections on the causes of pain, breakthrough cancer pain, pain treatment options, and tools to help cancer patients communicate effectively with physicians about their pain. The Web site also has a complete list of medications available to treat pain, information about complementary and alternative methods of pain control, and a section devoted to the special needs and issues of caregivers. In addition, Cancer-pain.org has an interactive section where patients and caregivers can exchange information.

The Web site’s news section provides patients with updates on developments in cancer pain treatments as well as links to other cancer sites, such as the National Cancer Institute (NCI), which enable patients to stay abreast of legislative issues affecting cancer research and treatment. ACOR also has plans to add a “Healthcare Professionals Corner” where professionals can exchange information on effective pain therapies, post relevant journal articles and new clinical research and recruit patients for clinical trials, as well as take accredited CME courses on cancer pain treatment.

“We hope this site helps educate patients about new advances in the understanding and treatment of pain, including breakthrough cancer pain, which can seriously diminish quality of life for cancer patients,” says Mr. Frydman. “Encouraging patients to exchange information about what works and what doesn’t, as well as dispelling the myth of addiction, are two of the reasons we have developed this site to be a resource for patients and caregivers.” Cancer-pain.org is supported through an educational grant from Cephalon, Inc.

Expert Analysis Highlights:

• Below are a few basic principles that will allow you to know your rights and get the records you need
• The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’)
• To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located
• Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up

Getting your medical records can be a huge barrier to getting a second opinion. Trying to figure out our complex healthcare system on the fly can be a daunting task. Here are a few basic principles that will allow you to know your rights and get the records you need to get a second opinion quickly.

The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’) and your pathology slides if a biopsy or surgery was performed.

The most important thing to remember is that your CT or MRI or PET scan is yours. You have a right to have a copy no matter what anyone tells you. The two ways a hospital typically provides you with a copy of your CT scan is 1) to provide a report or 2) to provide you with a CD-ROM copy of the actually pictures. In my experience, the report is not very helpful, and I never trust it in giving a second opinion. The actual CD-ROM is what a consulting doctor will insist on. In many instances, it’s the only thing needed to render an opinion about surgical respectability. In fact, as a routine practice, my office insists that a CD-ROM of a CT scan be mailed ahead of time to determine if an appointment is warranted. If it was never done, we simply get one done at our hospital prior to the appointment.

To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located and what their hours of operation are. You can usually find this out by calling the hospital’s operator or your doctor’s office. There is sometimes a $10-15 fee for the CD-ROM although many hospitals offer the service for free. Also, when traveling to another hospital, its a good idea to bring a second copy with you to your consultation visit.

There are also times when an outside CT is not readable on the computers of another hospital. Until President Obama’s national health electronic record is standard practice, then we will have to continue to hope that hospital computers can open outside CD-ROM’s. Luckily, hospitals can open more than half of outside CT’s using their software.

Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up. Alternatively, many hospitals have a system to send pathology slides directly from one hospital’s pathology dept to another. Of course this relies on them to not drop the ball so I recommend picking up the slides to ensure that the review is not delayed and things don’t fall through the cracks.

Expert Analysis Highlights:

• Lay media does a poor job of keeping a balanced perspective when reporting cancer information
• Study found that 95% reported exclusively on aggressive and expensive treatments such as chemotherapy, while only 13% mentioned that these treatments can fail
• Less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments; Only 8% mentioned the possibility that people die of their cancer
• Researcher from the study concludes, media “…play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear”
• That is why we are working to empower patients with accurate and straight-forward information on our site and our companion site www.patientresource.net

How well does the media do in reporting to you about the “hope” of cancer advances, while keeping a perspective that this is still a life-threatening disease that kills over a half million people each year?

Not very well, according to a study published in the Annals of Internal Medicine in March, 2010 by Drs  Fishman, Ten and Casarett from the University of Pennsylvania. They examined over 400 articles published in the lay press (i.e.: a public audience, not a medical journal) and found that a whopping 95% reported exclusively on aggressive and expensive  treatments –such as chemotherapy, bone marrow transplantation and radiation therapy—while only 13% mentioned that these treatments can fail. Moreover, less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments.

Please understand that I am not against the reporting of promising advances and the progress we are making, but I do think the media can do a better job. For example, I was recently interviewed on a new drug advance for melanoma, and was quoted (appropriately) that this was “ a single, not a home run”, meaning that is one of the first survival advances in the treatment of advanced melanoma, but probably won’t be used as a single agent to increase cure rates of melanoma. It was not reported that the drug can have serious side effects and that some patients died as a result of the treatment! On the one hand, if you are a patient for whom all other treatments have failed and you are facing the prospects of dying in the coming months, then getting a powerful drug with serious, sometimes life-threatening side effects may be your only choice. Or, if you have had potentially curative surgery but still have a risk of relapsing later on, you might have some pause about taking a drug that may interrupt or halt your present quality of life or even shorten your life. Doctors and cancer patients make these kinds of decisions every day based upon estimating the probability of success or failures among groups of patients. However, at the level of an individual patient, we don’t have a crystal ball! Some patients do better than expected and other do worse. We all have to make our best decision about the whether the benefits of a particular treatment outweigh the potential risks and complications and then accept the outcome as we go forward.

I’ll quote from a blog by Dr Casarett, one of the researchers on this study. “Of course, it’s not such a terrible thing if we can’t find what we need about cancer in newspapers and magazines. These are just one source of information that’s available to us. If we don’t find what we are looking for in one of these articles, we can look somewhere else. That’s why the real problem with these articles is not the information that’s missing from them, but rather the biased picture that they give of what it’s like to have cancer…..The most worrisome thing we found in these articles, though, was the way they carefully avoid mentioning death and dying. In fact, only 8% mentioned the possibility that people die of their cancer….So these articles play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear.” The full blog story can be found at www.huffingtonpost.com/david-casarett-md/cancer-news-offers-reader_b_499540.html.

Of course, this desire–indeed our passion– is to inform and educate cancer patients so they can learn about what they need to know, not just the things we want to hear. That is why we started Patient Resource Cancer Guides and its website www.patientresource.net and www.mycanceradvisor.com, so that cancer patients could learn about all aspects of the cancer journey, including the more difficult issues of pain management, treatment options and their complications, and the process of death and dying. We hope that empowering patients with accurate and straight-forward information will make a difference in their lives and the lives of their loved ones.

The abstract of the publication cited above is:

Fishman J, Ten Have T, Casarett D. Arch Intern Med. 2010 Mar 22;170(6):515-8.

Cancer and the media: how does the news report on treatment and outcomes?

BACKGROUND: Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality. METHODS: To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care. RESULTS: Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, chi(2) test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, chi(2) test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care. CONCLUSIONS: News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, USA. fishman1@mail.med.upenn.edu

Expert Analysis Highlights:

• Day before surgery can be an intimidating and confusing time
• Patients who do well the day before surgery describe being active with others
• Contrary to popular opinion, the days before surgery should be an active time with good hearty meals
• Exercising beforehand can set back atrophy by not allowing it to get a head start
• Remember the details of your instructions before surgery

The day before surgery can be an intimidating and confusing time. Anxiety about the outcome of the operation and long-term survival can be alleviated by knowing facts about surgery and tips patients have found useful in preparing.

First, stay active and eat well right up until the night before surgery. Unless you’re having colon surgery which often requires a bowel prep and an extra day of a restricted diet before surgery, go ahead and beef up! Contrary to popular opinion, the days before surgery should be an active time with good hearty meals. I tell many patients to treat themselves to a delicious meal in the days leading up to surgery and, depending on the operation, even the night before surgery. You won’t be eating much after the operation for a couple days at least, so to minimize the period of going without nutrition, its good to get some good calories in the system. Nutrition is also known to strengthen your immune system, which sometimes needs to work well during your recovery.

Along the same lines, stay fit. Go ahead and go to the gym and get some good exercise before surgery. The days after surgery are like being an astronaut in that your muscles get weak from lack of use (called atrophy). Exercising beforehand can set back atrophy by not allowing it to get a head start.

Here are some more facts that are good to ease fears. The data on surgery demonstrate that the operation itself is very standardized. In my field of pancreas surgery for example, nearly every experienced pancreas surgeon in the world performs essentially the same operation with minimal variation. Many patients are also worried about general anesthesia, perhaps based on scary movies or public legends of the olden days, but general anesthesia today has a major complication rate of only about 1 in 100,000. Anesthesia is very safe in the modern era, and its safety profile in medicine is among the best of any medical intervention.

Patients who do well the day before surgery describe being active with others. As a general note on patients that I see who are depressed and anxious, the more someone has a community, the less likely they are to experience depression or anxiety. Movies, performances, getting together with friends, and family gatherings are some of the activities patients find helpful in making the day before surgery a pleasant experience. Often times patients describe a great experience surrounding themselves with positive friends—people who are optimistic and enjoy life.

Finally, remember the details of your instructions before surgery: Nothing to eat or drink by mouth 8 hours before your scheduled surgery time, and bring your most recent CAT scan with you if your surgeon does not already have it.



Expert Analysis Highlights:

• It is important for the caregiver, for family members, and friends of a dying cancer patient to understand some of the basics about the physical act of dying
• Study finds that patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life
• Listed below are references on the internet that caregivers and families can go to about the death and dying process

Death is not an easy subject. As a consequence, there is too little discussion about it…even among loved ones. The videos shown above are a succinct and informative series for caregivers and loved ones in a family facing the emotionally difficult experience of watching someone go through the dying process. I know first-hand what this is like as both of my parents died from agonizing and mean-spirited cancers.

Death is a huge subject, and one that engages strong emotions. Every individual, and every family unit, faces this in different ways, for the human spirit and the sum of our life experiences are so unique!

It is important for the caregiver, for family members, and friends of a dying cancer patient to understand some of the basics about the physical act of dying and the issues associated with this process.  Hopefully, the four videos shown here will open up a dialogue and help in some small way to understand these issues.

Should a dying patient be shielded from their terminal state? In my opinion, no. That doesn’t mean that caregivers and patients should give up hope, but that they should be realistic in their expectations and be able to communicate the reality of the dying process in a loving and forthright manner. Knowing about the certainty of dying can oftentimes bring out intimate discussions with loved ones, including confronting fears about dying, that might otherwise not happen.

In a publication in the Journal of Clinical Oncology (April 10, 2010) on the topic: “Experiences and Attitudes of Patients with Terminal Cancer and their Family Caregivers toward the Disclosure of Terminal Illness”, the authors found that most patients with terminal cancer and their family caregivers preferred disclosure about their status. Patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life. Patients who were informed had a better quality of life and fewer symptoms and a lower rate of emotional distress than patients who came to their own conclusion that they were dying based on their worsening condition.

Care at the end of life focuses on making patients comfortable. They can still have goals of maximizing their quality of life and receive medicines and treatments to control pain and other symptoms. Some patients choose to die at home. Others enter a hospital or a hospice. When my parents were dying of cancer, I found that the Hospice Program in our area was an invaluable resource to help us mange through this difficult time.

The goal of palliative or end-of-life care is to improve the patient’s and the family’s quality of life by preventing and relieving suffering. This includes treating physical symptoms such as pain, and dealing with emotional, social, and spiritual concerns. Below are two more informative videos, and I have listed references available on the Internet for caregivers and families about the death and dying process. Also listed are helpful websites, specifically for caregivers. Finally, I have copied (below) an excerpt from the National Cancer Institute that has some helpful information.

Physical Contact Can Be A Simple Way to Bring Comfort to Your Dying Loved One:

Changes In A Dying Loved One’s Eating Habits Can Be Discomforting to Caregivers:

FOR ADDITIONAL INFORMATION:

American Society of Clinical Oncology: http://www.cancer.net/patient/Coping/End-of-Life+Care

American Cancer Society: http://www.cancer.org/Treatment/NearingtheEndofLife/NearingtheEndofLife/index

Cancer Care: http://www.cancercare.org/get_help/special_progs/caregivers.php

Caregivers: http://www.caregivers4cancer.com/

Mayo Clinic: http://www.mayoclinic.com/health/cancer/CA00048

National Cancer Institute on end-of-life issues: http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/patient

National Cancer Institute on Care giving: http://www.cancer.gov/cancertopics/caring-for-the-caregiver

SUMMARY FROM THE NATIONAL CANCER INSTITUTE (see website for details)

The following information can help answer some of the questions that many patients, their family members, and caregivers have about the end of life.”

1. How long is the patient expected to live?

Patients and their family members often want to know how long a person is expected to live. This is a hard question to answer. Factors such as where the cancer is located and whether the patient has other illnesses can affect what will happen. Although doctors may be able to make an estimate based on what they know about the patient, they might be hesitant to do so. Doctors may be concerned about over- or under-estimating the patient’s life span. They also might be fearful of instilling false hope or destroying a person’s hope.

2. When caring for the patient at home, when should the caregiver call for professional help?

When caring for a patient at home, there may be times when the caregiver needs assistance from the patient’s health care team. A caregiver can contact the patient’s doctor or nurse for help in any of the following situations:
• The patient is in pain that is not relieved by the prescribed dose of pain medication;
• The patient shows discomfort, such as grimacing or moaning;
• The patient is having trouble breathing and seems upset;
• The patient is unable to urinate or empty the bowels;
• The patient has fallen;
• The patient is very depressed or talking about committing suicide;
• The caregiver has difficulty giving medication to the patient;
• The caregiver is overwhelmed by caring for the patient, or is too grieved or afraid to be with the patient; or
• At any time the caregiver does not know how to handle a situation.

3. What are some ways that caregivers can provide emotional comfort to the patient?

Everyone has different needs, but some emotions are common to most dying patients. These include fear of abandonment and fear of being a burden. They also have concerns about loss of dignity and loss of control. Some ways caregivers can provide comfort are as follows:
• Keep the person company—talk, watch movies, read, or just be with the person.
• Allow the person to express fears and concerns about dying, such as leaving family and friends behind. Be prepared to listen.
• Be willing to reminisce about the person’s life.
• Avoid withholding difficult information. Most patients prefer to be included in discussions about issues that concern them.
• Reassure the patient that you will honor advance directives, such as living wills.
• Ask if there is anything you can do.
• Respect the person’s need for privacy.

4. What are the signs that death is approaching? What can the caregiver do to make the patient comfortable?

Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. It is important to remember that not every patient experiences each of the signs and symptoms. In addition, the presence of one or more of these symptoms does not necessarily indicate that the patient is close to death. A member of the patient’s health care team can give family members and caregivers more information about what to expect.

• Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient’s metabolism).

The caregiver and family members can plan visits and activities for times when the patient is alert. It is important to speak directly to the patient and talk as if the person can hear, even if there is no response. Most patients are still able to hear after they are no longer able to speak. Patients should not be shaken if they do not respond.

• Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient’s metabolism). Gently remind the patient of the time, date, and people who are with them. If the patient is agitated, do not attempt to restrain the patient. Be calm and reassuring. Speaking calmly may help to re-orient the patient.

• Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).

Speak to the patient directly. Let the patient know you are there for them. The patient may be aware and able to hear, but unable to respond. Professionals advise that giving the patient permission to “let go” can be helpful.

• Decreased need for food and fluids, and loss of appetite (caused by the body’s need to conserve energy and its decreasing ability to use food and fluids properly).

Allow the patient to choose if and when to eat or drink. Ice chips, water, or juice may be refreshing if the patient can swallow. Keep the patient’s mouth and lips moist with products such as glycerin swabs and lip balm.

• Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).

Keep the patient as clean, dry, and comfortable as possible. Place disposable pads on the bed beneath the patient and remove them when they become soiled.

• Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).

Caregivers can consult a member of the patient’s health care team about the need to insert a catheter to avoid blockage. A member of the health care team can teach the caregiver how to take care of the catheter if one is needed.

• Skin becomes cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).

Blankets can be used to warm the patient. Although the skin may be cool, patients are usually not aware of feeling cold. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns.

• Rattling or gurgling sounds while breathing, which may be loud; breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).

Breathing may be easier if the patient’s body is turned to the side and pillows are placed beneath the head and behind the back. Although labored breathing can sound very distressing to the caregiver, gurgling and rattling sounds do not cause discomfort to the patient. An external source of oxygen may benefit some patients. If the patient is able to swallow, ice chips also may help. In addition, a cool mist humidifier may help make the patient’s breathing more comfortable.

• Turning the head toward a light source (caused by decreasing vision).

Leave soft, indirect lights on in the room.

• Increased difficulty controlling pain (caused by progression of the disease).

It is important to provide pain medications as the patient’s doctor has prescribed. The caregiver should contact the doctor if the prescribed dose does not seem adequate. With the help of the health care team, caregivers can also explore methods such as massage and relaxation techniques to help with pain.

• Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms are additional signs that the end of life is near.

5. What are the signs that the patient has died?

• There is no breathing or pulse.
• The eyes do not move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open.
• The jaw is relaxed and the mouth is slightly open.
• The body releases the bowel and bladder contents.
• The patient does not respond to being touched or spoken to.

The time at the end of life is different for each person. Each individual has unique needs for information and support. The patient’s and family’s questions and concerns about the end of life should be discussed with the health care team as they arise.

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

Here are some hints to keep in mind to help you get the nutrition you need while you are undergoing cancer treatments. Be sure to review this list with your health-care professional before following any of these suggestions.

1) Try eating small meals and snacks all day instead of three large meals.

2) When you are hungry, eat more than usual.

3) Eat meals and snacks with sufficient protein and calories to help you keep up your strength.

4) You may find that your appetite is better in the morning, so eat more then. You may want to eat your main meal early in the day rather than at night.

5) Keep ready-to-eat snacks handy to nibble on during the day, such as cheese, crackers, ice cream, muffins, yogurt, granola bars and nuts.

6) If you are not interested in eating and can eat only one or two things, consume a liquid or powdered commercial meal replacement product, such as instant breakfast, for extra calories and protein.

7) On days when you don’t feel like eating, drink plenty of fluids, especially water. Other healthy liquids include fruit juices, sports drinks, broth and milk.

Because cancer treatments can weaken your body’s immune system, your body may not be able to protect you against infections at times, and so you may be told to avoid some foods that can expose you to bacteria, such as raw and undercooked meat, fish, poultry, eggs and tofu.

Once your treatment is complete, most of your eating-related side effects should disappear. Rather than staying on a high-calorie, high-protein diet, you should return to a conventional healthy diet when you start feeling better.