Healthy Living

Good nutrition will:

• Help prevent infections.
• Help maintain and rebuild muscles and damaged tissues.
• Provide you with energy helping you to maintain a sense of well being.

It can be a challenge to maintain good nutrition due to the side effects of the medications you may be taking.  These side effects may include nausea/vomiting, taste changes (dysgeusia), sore mouth and throat (mucositis), anorexia (lack of appetite), and diarrhea. The dietician will help you to meet your nutrient requirements by suggesting foods that may be easier to tolerate, or offering nutritional supplements if needed.

Decreased food intake and increased need for protein and calories can make it very easy for patients to lose weight, so it is important to be conscious of your intake:

1. Eat a balanced diet with a variety of foods, including fruits, vegetables, breads, pasta, meats and dairy products.
2. Include foods high in protein at each meal such as meat, fish, eggs, and cheese.
3. If you are a vegetarian, talk to the dietician for more protein options.

It is very important for you to drink plenty of fluids. Not drinking enough can lead to dehydration and other problems such as nausea, vomiting and kidney complications.

You should aim to drink about 6–8 cups or 2-3 litres of fluid each day. Here are a few suggestions to help you drink enough fluids:

• Always carry your water bottle with you and sip on it often. Make sure it gets a thorough cleaning every day.
• Dilute juices and other drinks with water.
• Remember how often you have filled your bottle to estimate how much you are drinking.

Avoid caffeinated drinks – strong teas, coffee, colas etc. – as these are of little benefit and may dehydrate you more.

Many patients undergoing treatment find that specific foods taste different. This may result from damage to the cells in your mouth that help to detect taste. Taste changes (dysgeusia) may also occur if there is decreased production of saliva in the mouth, causing a dry mouth (xerostomia).

Management

Taste changes are different for every person, and may last for several weeks. Coping with taste changes can be very challenging. Here are some tips:

1. Keep trying different foods and you might find a new favourite. Keep a list of foods that taste good to you.
2. Eat foods that taste good even if it means eating the same foods over and over again. Ask the dietitian for some help to make sure you are getting all the proper nutrients you need.
3. Try eating foods at cold or room temperature.
4. If food/meat tastes metallic, try marinating meat to hide the taste, using plastic utensils instead of metal, using glassware instead of metallic cookware, eating other protein rich foods instead of meat such as milk, canned fish, quiche, cottage cheese, milkshakes, puddings, custard, yogurt, cheese, deviled eggs, and cold sliced meat.
5. If food tastes too sweet, mix juice/high protein high calorie supplement drinks with water or milk, or add a pinch of salt to decrease the sweetness.
6. Good mouth care may help with taste changes; rinse your mouth throughout the day especially before and after meals, brush your teeth and tongue with a soft toothbrush.
7. For dry mouth, try the following foods to help stimulate your own saliva: lemonade, orange juice, cranberry juice, sugar free citrus candies, pickles, and plain yogurt. Avoid these foods if you have a sore mouth or throat.

Chemotherapy can lead to a condition called mucositis. Mucositis is an inflammation of the lining of your digestive tract and can lead to pain and sores in the mouth, throat and the passage to the stomach (esophagus).

Mucositis may last for days to weeks, and will usually get better around the time your blood cell counts begin to recover. Common side effects include dryness, redness, sensitivity, sores, ulcers, and taste changes.

Management

The soreness in your mouth and throat can make it very difficult to eat. Here are some tips:

• Inform the doctor/nurse if you develop sores in your mouth.  Medications are available to help you with the pain and the sores.
• A regular mouth care routine will help minimize the discomfort. You will receive instructions on mouth care from the healthcare team.
• Drink lots of fluids to help minimize mouth dryness. If your mouth is sore, cool or room temperature drinks are often more soothing than hot ones. Try diluted sport drinks, diluted juice and flat sodas instead of plain water.
• Avoid spicy or acidic drinks such as grapefruit or orange juice if your mouth is sore. Instead, stick to bland foods and juices such as apple or grape.
• Choose foods that are soft, moist and easy to chew and swallow, such as ice cream, popsicles, smoothies, high protein/calorie drinks, pudding, etc.

If you have parotid gland swelling (in the side of the neck) after total body irradiation, you may find that applying ice packs to the throat will help. It may be necessary for your BMT doctor to prescribe an analgesic until the swelling goes away. The swelling usually goes away within 12-24 hours.

Nausea/vomiting is a very common side effect with chemotherapy.  There are many different things that can trigger nausea such as motion, heartburn, food or other odours, and feeling full after eating. It is important to keep track of these triggers and to tell your doctor or nurse about them. This way, you can get the most effective anti-nausea medication.

Management

Prior to receiving chemotherapy or total body irradiation, you will receive medications that are very effective in minimizing nausea. These medications may be given by mouth, under the tongue, or through your Hickman® line on a regular basis throughout the therapy. Some of the anti-nausea medications cause a feeling of drowsiness and many patients find that they will nap more often..

Many different anti-nausea (also called anti-emetic) medications are available to you throughout the course of your treatment.  They can be prescribed for you based on your nausea/vomiting triggers.

What You Can Do

• Keep your mouth fresh by rinsing before and after meals/snacks.
• Eat small, more frequent meals/snacks throughout the day.
• Take clear fluids such as juice, broth or jello rather than a regular meal prior to chemotherapy or total body irradiation.
• Avoid spicy, fried and greasy foods. Starchy, bland foods are better tolerated. Try saltines, rice cakes, rusks, bread sticks, plain toast, pretzels, bagels, noodles, rice, plain congee, plain roti or digestive cookies.
• Put some crackers or biscuits by your bedside. Eating a little before you get up in the morning may help.
• If food odours trigger your nausea, try foods that are cool/cold.  Reduce cooking odours by using a kitchen fan and keeping pots covered.
• Eat whenever your appetite is the best.
• Try relaxation and distraction techniques before snacks/meals.
• Wear loose, comfortable clothing.
• A cold facecloth to your face or the back of your neck may be helpful.

A lack of appetite (anorexia) is very common during chemotherapy. Even though you may not want to eat, you still need good nutrition during and after treatment in order to maintain your strength and help your body recover. Here are some tips:

• Make every bite count. Eat high calorie, high protein foods. These foods include ice-cream/non-dairy frozen dessert, yogurt, sour cream, nut butters, smoothies, milkshakes, dried fruit, nuts, eggs, fish, meat, cheese, dried beans, peas and lentils. Drink homogenized milk instead of 2%, and try cream-based soups instead of clear soups.
• Make every sip count. Drink a high protein high calorie supplement drink throughout the day. Some commercial brands include Ensure® or Boost®. You can also make your own high protein high calorie drink by mixing 1 tablespoon of skim milk powder, 1 cup of cow or soy milk, 1 banana (or ½ cup of your favourite fruit) and ½ cup of ice-cream. Blend all of these ingredients and serve chilled.  
• Aim to eat 6-8 small meals daily instead of 2-3 large meals. Some small meal ideas include granola bars and milk, cheese and crackers, toast and peanut butter, bagel and cream cheese, pita bread and hummus or tzatziki, chips and dip, dried fruit, trail mix, pudding (rice, tapioca, flavoured) and cookies, fruit and custard.
• Eat when you feel hungry.
• Try experimenting by having traditional breakfast foods at dinner or vice versa.

Your treatment can create changes throughout the bowel that are similar to the changes in the mouth, throat and esophagus. One side effect that commonly occurs as a result of these changes is diarrhea, gas and cramping.

Diarrhea can cause your body to lose fluids and nutrients that can make you feel very weak and dehydrated. Like other side effects, the amount and frequency of diarrhea varies from patient to patient. It is very important to let your doctor and nurse know if you are having diarrhea. Uncontrolled diarrhea can lead to serious complications such as dehydration.

Useful Management Tips

The following tips might be useful if you are having diarrhea:

• Keep the perianal area clean to prevent skin irritation. A “sitz bath” or soak in warm water may be taken after bowel movements followed by the application of a mild cream to keep the area protected. Your BMT doctor may choose to prescribe a medicated cream for this purpose.
• Limit foods with caffeine such as coffee, colas, and strong tea. Caffeine can cause your body to lose even more fluid.
• Dairy products such as milk, cheese and ice-cream may make diarrhea worse. If you feel worse after eating these foods, consult the doctor or dietitian for more information. Lactose-free beverages might be better tolerated.
• Avoid high fat foods. If you feel worse after eating high fat foods such as deep fried foods, fatty meats, excess butter or margarine, or greasy snack food, then limit the use of these foods.
• High fibre foods might make diarrhea worse. Ask the dietitian for a list of low fibre foods to try.

If you have bloating, cramping or gas, then avoiding foods that can increase gas production might help. These include broccoli, cabbage, cauliflower, dried beans and peas, brussel sprouts, onions and carbonated beverages.

• Defrost meat and fish in the refrigerator or in the microwave. Defrosted foods should be used immediately. Do not refreeze food.
• Thoroughly wash fresh fruits and vegetables under running water before eating. Trim away any bruised areas.
• Use a separate cutting board for meat and seafood. Wash hands, knives and cutting boards very well with hot soapy water between uses.
• Sanitize all areas used for the preparation of raw meat or seafood with diluted bleach (5 ml bleach in 1 litre of water) or a cleaner containing bleach.
• Wash the tops of cans (e.g., soup, pop, fruit) before opening.

• Meat and seafood should be well cooked. There should not be any rare or pink portions.
• Poultry should be cooked to an internal temperatures of 85°C (180°F).
• Red meat, ground beef and pork should be cooked to an internal temperature of 75°C (165°F).
• Do not eat deli meats or salads made in the store, such as ham salad, chicken salad, egg salad, tuna salad or seafood salad.
• Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable products may be eaten.
• Barbecuing and grilling should be done carefully. Make sure meat is well cooked.
• Do not eat raw or undercooked seafood, especially sushi, clams, shrimp, oysters, squid, octopus, and marinated fish.
• Do not eat refrigerated smoked seafood unless it is contained in a cooked dish such as a casserole. Canned or shelf-stable seafood may be eaten.
• Do not drink unpasteurized milk or eat foods that contain unpasteurized milk.
• Do not eat unpasteurized cheeses.
• Do not eat soft cheeses such as feta, Brie, Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco and Panela, unless they have labels clearly stating they are made from pasteurized milk.
• Avoid yogurt and ice cream from “soft-serve” machines.

• Keep the refrigerator at 4°C (40°F) or lower; keep the freezer at -18°C (0°F) or lower.
• Keep raw meat, seafood and poultry separate from other food that will not be cooked and away from cooked/ready-to-eat foods.
• Perishable foods should not be unrefrigerated for over 2 hours.
• Any egg or mayonnaise dishes should not be unrefrigerated for more than 2 hours.
• Note all dates on foods and use before the expiry or “best before” date.

• Wash cutlery or dishes between use with raw and cooked meats.
• Wash your dishes with hot, soapy water and rinse with hot water.
• “Air dry” dishes instead of using a dishtowel.
• If you use a dishwasher, use the hot setting.
• If you use paper plates and plastic utensils, discard them after each use.

Fatigue is the most common symptom felt by people with cancer. Many factors, in addition to the underlying cancer itself, can contribute to cancer related fatigue. These include anemia, poor nutrition, depression, medication side effects, poor sleep and being less active.

What you can do to help:

• Tell your healthcare team. It’s possible that you may need medicine, a nutritional supplement or a blood transfusion to help with your symptoms.
• Think about the “4 P’s of Energy Conservation”

1. Prioritize: When you have more than one thing to do, begin with the most important task to make sure it gets done.
2. Plan: Plan your activities in advance to avoid doing extra trips.
3. Pace: Never rush. Rest often and rest before you feel tired.
4. Position: Sit when you can to do tasks. Avoid bending and reaching too much.

• Rest when you need to. Take short naps of 10 or 15 minutes rather than longer naps during the day. Too much rest, as well as too little, can make you feel more tired. Save your longest sleep for the night.
• Balance your rest and activity. Keep track of when you feel most tired and when you have more energy so you can plan activities at the best time.
• Try to limit the length of visits with family and friends. In hospital, ask your nurse if you need help limiting the length of time visitors stay.
• Update family and friends with group texts/emails or social media (or delegate this task!).
• Let others help. Ask a friend or family member to update others on your condition and to help grocery shop, cook, or babysit.
• Light exercise such as walking around the block or unit can boost your energy.

Regular exercise and physical activity are important.

• You will feel better mentally and physically.
• You will keep your muscles, heart and lungs in shape.
• You will sleep better 
• You will maintain your strength and circulation.

When you are feeling unwell, do what you can. Regular exercise can simply mean getting up and walking several times a day.. Even a short walk around the unit or your house is good for you. 

While you recover, walking is probably the best activity to start with. Over time, your stamina and strength will improve. Your physiotherapist can help you plan a re-conditioning program that includes gradual increases in activity.

Here are some activities you can do to keep up your strength while in hospital and at home:

• Walk in the hallway when you are allowed to do so  at least 3 times a day. 5 times a day is better!
• Do at least 2 laps around the Unit; 3 or 4 laps each time is great. If you feel tired, one lap is better than nothing. 
• If you feel unwell, do what you can – a short walk several times daily is better than only one big long walk.
• Sit in a chair to read or watch television instead of lying in bed. Sit in a chair for all of your meals.
• Marching on the spot is a very good exercise to keep up your strength and balance. Stand up and lightly hold a windowsill or stable furniture (not the IV pole).. Good posture is important.
• Do leg and arm exercises daily, especially if you are not walking much.

If you have a central line, PICC or Hickman/Trifusion line you can move that shoulder in any direction but avoid strong swinging or forceful stretching. Avoid heavy resistance exercise on that side and be careful not to pull on the line. Avoid heavy lifting above your head.

Exercise is very important but there may be some restrictions at first. Mention any exercise activities to the BMT doctor before engaging in them. Your Physiotherapist will also help you with exercises.

Platelets

Platelets help stop bleeding. When you exercise, especially against resistance, you can cause very small injuries to tissues and small blood vessels. This is normal and usually heals easily, causing no problems. However, when your  platelets are  low, bleeding may not be stopped as effectively. Here is what you need to know:

• Platelets less than 10 = limit activity. Be extra careful to avoid falls or injury. Walk in room only
• Platelets 10 – 20 = gentle stretching, walking, exercises without resistance, stationary bike without resistance 
• Platelets 20–50 = light resistance (theraband or hand weights), walk briskly, stationary bike with some resistance, step-ups/stairs 
• Platelets 50 – 100 =  jogging, resistance exercise (theraband or weights), massage
• Platelets greater than 100 = heavy resistance exercises, deep massage  

There are no restrictions on exercise once your platelet count  returns to normal. However, ask your doctor before taking up sports and activities that put you at risk for injury such as contact sports and skiing. 

Hemoglobin

Hemoglobin is in the red cells of your blood. Hemoglobin carries oxygen around your body, which every cell needs for energy to carry out normal processes.  Normal hemoglobin levels are: 115 to 150 for women and 135 to 170 for men.

If the hemoglobin count is less than normal, you may tire more quickly. You may find it helps to go more slowly and do shorter periods of activity more frequently. If you get short of breath or tired, slow down or rest before continuing.

Short walks on flat surfaces are a great option.

You may be given infusion of red blood cells if your hemoglobin level is low.

White Blood Cells

When your neutrophil count is low, you will be limited in where you can go. You should avoid crowds, groups of people etc.  It is important to wash your hands frequently. You may be asked to stay in your room or stay on the unit. 

Walking around the hospital is not allowed if you are admitted. The physiotherapist can give you exercises to do in your room or on the unit if allowed to walk in the hall. 

It is important to avoid getting sick as much as possible. You can still be active and exercise when your neutorphils are low. Your activity level will depend on your platelets and hemoglobin level.

Human sexuality is often a very difficult issue for people to discuss in the best of times. When this is compounded by a diagnosis of a life-threatening illness and its treatment, it often becomes even more difficult to discuss.

Issues of reproduction and sexuality are important because they have implications for your future. This is one of the major reasons why we are discussing them here. Please know that you can ask your health care team any questions about this topic.

Most men and women experience a temporary decrease in libido (desire). This may be due to tiredness, weakness, a change in how they feel about their appearance, or a general feeling of illness. Remember, sex requires extra energy!  It is an individual thing, but it can take several months or more for interest to return. Resuming intimate relationships will take patience and time.

It is important for both partners to be patient and sensitive to each other’s needs. Remember there are many ways to express love and closeness. Initially you may just want to sit close together, hold hands, and hug each other. Touching and caressing takes much less energy than sexual intercourse and can be just as intimate and satisfying.

Chemotherapy agents are not known to directly affect desire, orgasm or ejaculation For many patients, however, decreased libido (desire) is common, but usually temporary. Due to chemotherapy or radiation therapy, semen may appear brown or orange. This is temporary. Patients receiving chemotherapy should wear a condom during sexualcontact , for up to seven days after the last dose of chemotherapy  Semen will be cytotoxic and pregnancy needs to be avoided. Body fluids such as vagianl fluid will also contain small amounts of cytotoxics. A condom is recommended for intercourse and 

Resuming relationships will take patience and time. Communication with your partner is the key. Touching and caressing take much less energy than sexual intercourse and can be just as intimate and satisfying.

During your recovery engaging in sexual intercourse can put you at risk for infection and bleeding. We recommend the following guidelines:

• Do not engage in sexual activity if you or your partner has an infection, such as a cold, upper respiratory infection, open sores or cuts, or herpes/cold sores.
• Do not engage in sexual intercourse if your platelet count is less than 50.
• Do not engage in sexual activity if your neutrophil count is less than 0.5
• It is advised for couples to use birth control, preferably condoms. The use of condoms is preferred to protect the immunocompromised patient from infection. Discard condom after each use. All questions regarding birth control should be addressed by your doctor.
• if you are a women undergoing chemotherapy treatment and wish to receive oral sex,  your vaginal fluid will be cytotoxic. This is very hard to avoid while preforming oral sex and therefore oral sex should be avoided until 48 hours after the last chemotherapy dose 
• If you are a man undergoing chemotherapy treatment and wish to receive oral sex, you need to wear a condom to prevent the sharing of body fluids. This should be avoided for 48 hours after the last dose due to cytotoxic body fluids. 
• Saliva should not be shared as it will be cytotoxic for 48 hours after the last dose of chemotherapy – example performing oral sex and french kissing. 
• Avoid the use of spermicides as these may irritate the penis and/or vagina.
• Do not use intrauterine devices (IUDs) or diaphragms.
• It is advised  to urinate after sex and to wash thoroughly to reduce the chance of urinary tract infections.
• Due to immunosuppression, women are more likely to develop vaginal infections/dryness, and are advised to use a water-based lubricant.
• Avoid anal sex.
• If not in a long-term relationship, consider telling potential partners about your history, so proper precautions can be taken.
• Avoid multiple sex partners.

Here are some points to consider when thinking about intimacy:

• Sexuality is an important part of many relationships and needs to be addressed, even during treatment.
• You are not alone. Most cancer patients and their partners have issues pertaining to sexuality and their treatment.
• Do not make the mistake of defining your sexuality on the basis of your desire/ability to have intercourse. This puts too much pressure on you, and is a total falsehood. Human sexuality is much more fluid than this.
• Understand that sexual issues during treatment arise for a number of different reasons. These include physical symptoms (eg pain, nausea) that may prevent intercourse from happening, the stress of your current situation may create performance issues, and you or your partner may have issues with self-image regarding body changes due to the disease or the treatment.
• It is tremendously important to first acknowledge your feelings about your sexual self, and any reasons why thinking about your own sexuality is difficult. Then share this with your partner.
• It is important for partners to maintain open communication and to continue physical contact like touching and tenderness to support and affirm each other.
• Don’t be upset if you are unable to have intercourse for a time. It is all about perspective. Think about it as an opportunity to re-connect with your partner in a very special way.
• Don’t be afraid to take things slowly. Don’t think you need to go ‘back to normal’ after your treatment. This will take some time. You may have a ‘new normal’.
• Don’t be afraid to have the conversation. Talk to your partner about sex. Chances are they are dealing with some of the same issues you are.
• Get help if you need it. There are many counsellors who specialize in human sexuality, and it may make all the difference.

Freezing (cryopreservation) of fertilized eggs (ova), called zygotes, may be possible prior to receiving high-dose therapy. Your BMT physician can discuss this in more detail if you wish. This is a time consuming process and may not always be possible. 

Sperm banking is a process available that involves freezing and storing sperm in liquid nitrogen. This sperm may be used at a later time for artificial insemination The patient’s underlying disease and exposure to chemotherapy or radiation can decrease sperm counts. Patients interested in sperm banking should discuss this with their physician. For some patients, treatment cannot be safely delayed and if the sperm count is low, sperm banking may not be possible. Patients should discuss this with their physician if they have concerns or questions.

There is a fertility clinic very close to VGH that you can be referred to if you wish. It is possible to collect a sample here at VGH and have someone take it to clinic for you. There are fees associated with the storage and freezing of sperm that you will need to pay annually.  Please ask your health care team if you would like more information 

Support for oncology patients:

https://www.olivefertility.com/ 

https://fertilefuture.ca/     

Women will notice that their menstrual cycle, or period, may become irregular or stop following chemotherapy or a blood and marrow transplant. If it does not stop, hormone replacement therapy may be given to stop the monthly cycle. This decreases the risk of excessive blood loss while your platelet and hemoglobin counts are low. Provera or Ovral are drugs commonly used to stop menstrual flow. Once your counts have recovered enough that blood/platelet transfusions are no longer necessary, these medications can be discontinued. Due to your increased susceptibility to infection, if you do have a period, avoid the use of tampons or menstrual cups. You may find your menstrual period is longer and heavier than usual

After chemotherapy or blood and marrow transplant, menopausal symptoms can occur due to a lack of ovarian hormone production. Hormones are chemicals made by the body that control many different functions of the body. Menopausal symptoms include hot flashes, vaginal dryness, and inflammation of the vaginal wall, pain during intercourse, irritability, and decreased libido (desire).

Hormone replacement therapy such as Premarin or Provera may be used to lessen these symptoms and to prevent bones from becoming weak and brittle, leading to osteoporosis. Some women find that using lubricants, gels or other vaginal creams such as K-Y jelly (Vaseline is not recommended) may help to relieve some of the vaginal discomfort. It is important to discuss these issues with your gynecologist or BMT doctor.