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:

• There is some evidence, although somewhat controversial, that acupuncture can be effective in reducing frequency of hot flashes
• A small, 12-week study concluded “Acupuncture appears to be equivalent to drug therapy…”
• A large, 4-week study did not demonstrate a statistically significant reduction of hot flashes
• However, the 4-week study concluded: “We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.”

Hot flashes can be a debilitating condition for cancer patients who are being treated with chemotherapy or hormone therapy. This includes women with breast cancer and men with prostate cancer. I have written about this condition previously, including a listing of various medications that can be taken to reduce the frequency and intensity of hot flashes. (for more information, read Study May Help Cool Hot Flashes for Cancer Patients).

There is some evidence, although somewhat controversial, that acupuncture can be effective in women…and in men…who suffer from hot flashes. In a scientific study conducted at Henry Ford Hospital and published in the Journal of Clinical Oncology (February 1, 2010; vol. 28:pages 634-40; abstract listed below), 50 breast cancer patients volunteered for a  randomized controlled trial that tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor), a commonly used drug for hot flashes. The investigators concluded that: “Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.”

However, the evidence for acupuncture is not compelling. For example a slightly larger study from Memorial Sloan Kettering Cancer Center in 2007 did not convincingly demonstrate that acupuncture worked (J Clin Oncol. 2007 Dec 10; volume25:page 5584). They concluded: “Hot flash frequency in breast cancer patients was reduced following acupuncture. However, when compared with sham acupuncture, the reduction by the acupuncture regimen as provided in the current study did not reach statistical significance. We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.” This is an important point, since the positive Detroit trial administered acupuncture for 12 weeks while the New York trial was only 4 weeks in duration. FYI, sham acupuncture is a commonly used control group using techniques that are not intended to stimulate known acupuncture points.

While the evidence about the value of acupuncture treatments for refractory hot flashes are still preliminary, there seems to be enough potential value for this to be considered as an adjunct to conventional treatments for hot flashes, as described in previous blogs (for more information, read Study May Help Cool Hot Flashes for Cancer Patients). More research on this subject is needed.

Please read the abstracts below for more information. An interesting small study about acupuncture for hot flashes was recently reported in men with prostate cancer who were receiving hormone therapy (abstract listed below).

Acupuncture for Hot Flashes in Patients With Prostate Cancer.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K.

Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon.

Urology. 2010 May 20. [Epub ahead of print]

Abstract

OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer. METHODS: Men who had a hot flash score >4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients’ daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined. RESULTS: A total of 25 men were enrolled from September 2003 to April 2007. Of these, 22 were eligible and evaluable. After 4 weeks, 9 (41%, 95% confidence interval 21%-64%) of 22 patients had had a >50% reduction in the hot flash score. Of the 22 patients, 12 (55%, 95% confidence interval 32%-76%) met this response definition at any point during the therapy course. No patient had a significant increase in hot flash score during therapy. A reduced hot flash score was associated with improvement in the hot flash-related quality of life and sleep quality. CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit. Additional studies of acupuncture for hot flashes in this population are warranted. Copyright © 2010 Elsevier Inc. All rights reserved.

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Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial.

Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA.

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

J Clin Oncol. 2010 Feb 1;28(4):634-40. Epub 2009 Dec 28.

Abstract

PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor). PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being. CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.

PMID: 20038728 [PubMed - indexed for MEDLINE]

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

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

Dr Gerald Chodak talks about the types of drugs used for aggressive prostate cancer that was refractory to hormone treatments. He discusses the indications, benefits and side effects of taxotere (docetaxel, Sanofi Aventis). Here’s other information from our companion website, patientresource.net, that you may find helpful:

Online prostate cancer calculators, also called nomograms, provide forecasts of prostate cancer outcomes by calculating the statistical probability of disease progression or patient survival after treatment by comparing your individual information to data from many hundreds or thousands of other prostate cancer patients. Two particularly comprehensive calculators are available on Web sites from Memorial Sloan Kettering Cancer Center in New York (www.nomograms.org) and the University of Montreal (www.nomogram.org) .

The advantage of these predictive tools is that they are individualized to your particular condition and characteristics. The calculators ask you to respond to questions about your PSA level, age, tumor stage, Gleason score, biopsy cores and planned treatment or other information. Calculators are available to help you and your physician make treatment decisions before and after initial treatment and after a relapse.

However, as more men are diagnosed with lower-risk disease, these nomograms are proving less useful. For those men with newly diagnosed prostate cancer the great majority will be assessed as low or intermediate risk. These nomograms provide limited information to distinguish those men whose cancers will be cured from those in whom treatment will fail. In men with low or intermediate risk disease, new approaches and technologies involving biological markers are being developed to improve your doctor’s ability to estimate the curability of the cancer (see Biological Markers below).

You should talk with your physician or medical team to help you interpret the results of these calculators and make decisions about any planned treatment. The statistics you receive by filling out these nomograms will help you have an informed discussion with your doctor.

Here is a nice clip from the UK for women that has some practical advice about sexual issues after cancer treatments. You should talk with your doctor before treatment begins to find out what to expect in terms of sexuality issues. If there are treatment options, make sure to talk about the side effects of each option. Ask your doctor when it is safe to resume sexual activity after treatment. During and after treatment, talk to your doctor or nurse if you have symptoms that interfere with sexual desire or sexual performance. If you feel uncomfortable talking with your doctor or nurse about your sexual symptoms, ask for a referral to an appropriate health care professional or support group.

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

There are a wide range of reasons for changes in sexuality during cancer treatment, and the reasons relate to the treatments themselves as well as to other side effects of treatment.

Surgery has a variety of effects on sexuality. Removal of all or part of a reproductive organ decreases hormone levels, which can lead to overall loss of sexual desire. Such surgery can lead to premature menopause in younger women, and may make sexual intercourse painful or difficult for younger and older women. Surgery in the pelvic area in men can damage the nerves leading to the penis, causing erectile dysfunction. Lastly, surgery that changes body appearance, as with removal of a breast or a testicle, can affect how a person feels about his or her body image. A negative body image can change how you feel about your sexual desirability.

Chemotherapy or radiation therapy to the pelvis may damage the ovaries in women or the testicles in men, both of which can reduce the amount of hormones produced. This loss of hormones may cause a loss of sexual desire in men and women, premature menopause in younger women, and erectile dysfunction in men.

The side effects of cancer treatments also play an important role in sexuality. Side effects such as fatigue, nausea and vomiting, pain, diarrhea, and mouth sores can substantially reduce a person’s interest in sex and his or her feelings of desirability.

Some treatments are available for physical sexual issues. For example, vaginal dryness can be treated with vaginal moisturizers and lubricants. Several drugs are available for erectile dysfunction, including sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). These drugs may not be appropriate for every man, and men should talk to their doctors about the risks and benefits. Hot flashes in both women and men have been relieved with low doses of antidepressants such as fluoxetine (Prozac), venlafaxine (Effexor), duloxetine (Cymbalta), and paroxetine (Paxil). Management of side effects that interfere with intimacy can help you feel better overall, which may help you feel more desirable and more interested in sex.

Open communication with your spouse or significant other is key to maintaining a good intimate relationship. You and your partner should share concerns and fears. Talk about ways to be intimate other than with sexual intercourse. You should both understand that it is safe to have sex during cancer treatment (unless your doctor tells you otherwise). Counseling (individual, couples, and/or sex therapy) may be helpful.

A diagnosis of cancer can be scary, and understanding a treatment plan confusing. To gain more information, it is sometimes wise to seek a second opinion or advice from another qualified cancer specialist or group of specialists before or even after you begin treatment.

If you are asked to consider alternatives, such as surgery or radiation or chemotherapy or hormone therapy, you might want to hear from each type of oncologist who gives that treatment. It’s all right to look at all your options. A second opinion could save your life or better protect your quality of life.

Options for getting a second opinion:

- Talk to a cancer specialist in another specialty or medical group.

- Ask that your case be presented to a tumor board or tumor conference at your hospital.

- Ask to get a second opinion on your pathology reading, especially if there is any controversy in making a complete diagnosis.

- Seek the advice of a renowned cancer expert usually in a comprehensive cancer center especially if your situation is complicated or uncommon.

For more information, see our companion website: www.patientresource.net. Here’s some of the content from patientresource.net that you may find useful:

Getting a second opinion involves asking another cancer specialist or group of specialists to review your medical records and confirm your doctor’s diagnosis and treatment plan. Other specialists can confirm your pathology report and stage of cancer and might suggest changes or alternatives to the proposed treatment plan. They can also answer any additional questions you may have. There is often collective wisdom gained from the experience and opinions of different oncology specialists who are experts in your type of cancer.

There are lots of reasons for seeking a second opinion. Some doctors may favor one treatment approach, while others might suggest a different combination of treatments. Doctors in each oncology specialty bring different training and perspectives to cancer treatment planning. Another doctor’s opinion may change the diagnosis or reveal a treatment your first doctor was not aware of. You need to hear arguments for all of your treatment options. A second opinion is also a way to make sure your pathology diagnosis and staging are accurate, and that you are aware of clinical trials that you might want to consider.

If you are asked to consider alternatives, such as surgery, radiation, chemotherapy or hormone therapy, you might want to hear from each type of oncologist who provides that treatment. It’s all right to look at all your options; a second opinion could save your life or better protect your quality of life. Most doctors welcome another doctor’s opinion.

Second opinions are also valuable if you live in a small town or rural area where there may not be as many oncology specialists, especially if you have an uncommon type of cancer or might need a highly specialized or complicated type of care. If so, you may want to get an opinion from specialists at a larger medical center or comprehensive cancer center with particular expertise in treating your type of cancer.