This guide is designed to help you understand and manage anorexia and weight loss. It provides practical information on how you can maintain an adequate intake of food.

Symptom and Description

Anorexia refers to a loss of appetite. Anorexia can lead to decreased food intake, loss of weight, malnutrition, and loss of muscle mass and strength. The combination of anorexia, weight loss, malnutrition, and loss of muscle mass and strength are known as cachexia. Anorexia is common in cancer and can occur as a result of disease or it can be related to the side effects of cancer treatment. Treatments for cancer often cause side effects such as nausea or changes in the oral mucous membranes. These problems may interfere with the ability to maintain normal food intake. This is usually temporary, lasting only until the side effects go away. Sometimes changes in appetite are related to the cancer itself. Cancers can cause changes in appetite and metabolism. The reasons why this happens are not entirely clear—it is an area of ongoing research.

Prevention/Management

Nutritional care is an important component of overall cancer care. It is important to be aware of your nutritional status from the time of diagnosis. Consuming adequate calories and maintaining your weight can help you to feel your best during cancer treatment. Preventing weight loss and muscle wasting is the goal.

1. Appetite stimulation:

• Identify your appetite pattern and use it to guide your food intake. Sometimes people have a normal appetite in the morning with anorexia worsening as the day goes on. You should eat food during those times when your appetite is best.
• Avoid large meals. Eating smaller, more manageable meals 5–6 times per day is recommended.
• Monitor your intake carefully. It is important that you consume enough calories. If you are unable to do this, nutritional supplements may be used.
• Make sure that your diet contains foods that are good sources of:
  • Protein: fish, chicken, meats, eggs, nuts, beans
  • Carbohydrates: breads, cereals, grains, pasta, fruits
  • Fats: whole milk, ice cream, oils, olives, peanut butter
• Take a multivitamin daily.
• Limit the intake of fluids with meals. Fluids lead to an early sense of fullness and may limit the amount of food you are able to eat. Fluids should be taken about 1⁄2 hour before meals or between meals.
• Keep "favorite" foods readily available. These can be prepared in advance so that they are ready whenever the urge strikes.
• Enlist the assistance of friends and family in the preparation of meals or "favorite" food reserve.
• Do some form of mild exercise for about 20 minutes a day. This helps to keep your muscles stimulated and your strength up. A walk prior to meals will help to stimulate appetite. Exercise following meals assists with gastric emptying.
• Eat in a pleasant space.
• Ask your doctor or nurse if pharmacologic methods of appetite stimulation are right for you. A medication called megestrol acetate (Megace) has been shown to increase appetite and weight in some groups of patients. Side effects may include increased blood pressure, blood clots, and fluid retention.
• Eliminate food restrictions whenever possible. For example, low-salt or restricted-calorie diets can often be eliminated. You should double-check with your physician or nurse before doing this.
• Monitor yourself for the development of any symptoms that may interfere with your ability to eat. Examples include nausea or sores in your mouth. If symptoms develop, they should be reported to your healthcare provider, who can provide guidance on how you can manage the symptom. Symptoms that can interfere with your food intake should be managed very aggressively.

2. Maintenance of weight:

• Monitor your weight. Use the same scale and weigh yourself at about the same time each day.

Follow-up

You should notify your doctor or nurse if any of the following occur:

• You are unable to consume or keep down fluids or food.
• You experience symptoms that limit your intake of food/fluids.

Appetite changes are common with cancer and cancer treatment. Individuals with poor appetite or appetite loss may eat less than usual, not feel hungry at all, or feel full (satiated) after eating only a small amount. Ongoing appetite loss can lead to weight loss, malnutrition, and loss of muscle mass and strength. The combination of weight loss and loss of muscle mass, also called wasting, is referred to as cachexia. Causes Appetite loss is common in people with cancer. Certain types of cancer, including ovarian, pancreatic, and stomach cancers, can cause a loss of appetite, usually by affecting a person's metabolism. Cancer-related weight loss is not like starvation, and eating enough food doesn't solve the problem—unlike starvation, weight loss associated with cancer results in a loss of muscle mass. Appetite loss also occurs in 80% to 90% of people with advanced cancer for various reasons, including changes in metabolism, early satiety (feeling of fullness) from ascites (accumulation of fluid in the abdomen), and other symptoms of cancer. Other causes of appetite loss include chemotherapy, immunotherapy, and sedative medications (drugs that cause feelings of calm or sleepiness). In addition, radiation treatment or surgery to any part of the gastrointestinal system, such as the stomach or intestines, can also cause appetite loss. Several of the side effects commonly experienced with chemotherapy and radiation treatment may also cause appetite loss, including: Nausea and vomiting Mouth sores and mouth pain Dry mouth Swallowing difficulties Chewing difficulties Changes in taste and smell Pain Fatigue Depression Management If possible, the first step in treating appetite loss is to treat the underlying cause. Treatment for conditions such as mouth sores, dry mouth, pain, or depression should help improve appetite. Additional treatment for appetite loss and associated weight loss may include appetite-stimulating medications, medications that help food move through the intestine, nutritional supplement drinks, and tube feeding (often a nasogastric tube that passes through the nose into the stomach). Although you may not feel like eating, it is important to remember that good nutrition and maintaining a healthy weight are important parts of overall cancer care and recovery. Eating well can also help a person better cope physically and emotionally with the effects of cancer and cancer treatment. The following tips may be helpful in maintaining proper nutrition when your appetite is poor. Eat five to six small meals a day and snack whenever you are hungry. Determine what times of day you are hungry, make sure to eat at those times, and do not limit how much you eat. Eat nutritious snacks that are high in calories and protein (for example, dried fruits, nuts, yogurt, cheeses, eggs, milkshakes, ice cream, cereal, pudding, and granola bars). Keep favorite foods on hand for snacking. Add calories and protein to foods by adding sauces, gravy, butter, cheese, peanut butter, cream, and nuts. Drink fluids between meals rather than with meals. Drinking during a meal can make you feel full too quickly. Choose nutritious drinks, such as milk, milkshakes, and juices. Ask family members or friends to prepare foods when you are too tired to cook. Ask them to shop for groceries or buy precooked meals. Try to eat in pleasant surroundings and eat meals with family or friends. Eat food that is cold or at room temperature to decrease its odor and reduce its taste. Ask your doctor about ways to relieve other gastrointestinal symptoms, such as nausea, vomiting, and constipation. If your sense of taste is diminished, try adding spices and condiments to foods to make them more appealing. Try light exercise, such as a 20-minute walk, about an hour before meals to stimulate your appetite. (Consult your doctor before starting an exercise program.) Exercise also helps maintain muscle mass. Meet with a registered dietitian (RD) for additional advice on meal planning.

This guide will help you to recognize the early signs of bleeding. Because of your condition and your treatment, this could be very important and will help your care team to know whether your bleeding is serious or an expected result of your therapy.

Symptom and Description

Bleeding occurs when blood escapes from a blood vessel. Bleeding can happen anywhere in your body. It can be external or visible, such as an open cut, nosebleed, or bleeding hemorrhoid, or it may occur inside your body, such as in your stomach, lung, brain, or bladder. Slow bleeding can have little effect or can make you tired, weak, and short of breath. Sudden bleeding can cause severe weakness, dizziness, and pain. Bleeding most often occurs when platelets (cells in the blood that helps stop bleeding) are low. This may be a problem for people with leukemia or other tumors involving the bone marrow, as well as for those receiving chemotherapy or radiation therapy. The risk of bleeding increases with fever and infection, especially when the platelets are low or are dropping quickly.

Prevention

Your skin and the lining of your mouth are protective barriers for your body. Keeping them clean and free of debris is important in decreasing infection and risk for bleeding.

Skin

• Bathe and clean the perineal (crotch) area daily, pat dry and apply personal hygiene moisturizer
• Use skin lotion (aloe based) to prevent dryness and breaks in skin
• Protect skin from cuts and scrapes and sharp objects, wear gloves at all times to protect hands
• Shave using an electric razor
• Trim and cut nails, seek professional manicure to trim cuticles, apply lotion daily
• Avoid falling, contact sports, and other activities with a potential for injury, use a walker or cane

Mouth and mucous membranes

• Cleanse your mouth after each meal and before bedtime—follow approved oral care regimen of brushing, flossing, and rinsing with baking soda and water after each meal and before bed time.
• Avoid irritating foods that can harm the lining inside your mouth
• Keep lips moistened—apply aloe based lubricant frequently
• Use a soft-bristle toothbrush; avoid dental floss if gums are inflamed or bleeding
• If your platelets are low, you may need to use toothettes, or swabs, instead of a toothbrush
• Use mouthwash that does not contain alcohol, which can be drying
• Check with your doctor or nurse before having any dental work done
• Avoid vigorous nose blowing, cleanse nares with q-tip and salt water
• Humidify room air to prevent dryness; drink 8 to 10 glasses of water a day

Digestive system

• Promote normal bowel patterns, avoiding straining; increase consumption of fiber, fluids, fruits and vegetables, cereals, Metamucil cookies, raisens, oat cereals
• Use stool softeners or laxatives to prevent constipation
• Maintain proper diet and exercise
• Avoid rectal suppositories and enemas

Genitourinary system

• Maintain adequate hydration; drink 8 to 10 glasses of fluid a day
• Avoid douches, vaginal suppositories, and tampons
• f your platelet count is below 50,000/
  l, avoid sexual intercourse

General tips

• Avoid medications that can prolong bleeding, such as aspirin or aspirin-containing products (such as over-the-counter cold medications) and ibuprofen (Motrin, Aleve, Advil)

Management

You should report any of the following signs of bleeding to your doctor.

• Skin: A fine red rash that looks like pinpoint dots, usually appearing on the feet and legs; increased bruising; or persistent bleeding from cuts or scratches.
• Eyes: Bleeding into the whites of the eyes, inability to see normally
• Mouth and nose: Blood blisters, blood oozing from gums, blood-tinged saliva, bleeding mouth sores, nosebleeds
• Digestive system: Blood in vomitus, this can be bright red blood or blood that looks like coffee grounds, blood in stools, black tarry stools
• Respiratory system: Blood in sputum or with coughing, shortness of breath
• Urinary system: Blood in urine, pain or burning on urination, cramping, and increased frequency of urination, vaginal bleeding
• Other: Severe headaches, increased weakness, difficulty waking up or disorientation, pain in joints and muscles

Procedure

• If bleeding does occur, stay calm; sit or lie down
• If bleeding is external, such as a cut or wound, apply pressure for at least 10 to 15 minutes
• If you have a nosebleed, sit in an upright position and apply firm pressure to the nostrils just below the bridge of the nose. You may also apply an ice bag to the bridge of the nose.
• If bleeding is on a leg or arm, raise the limb above your heart
• Use an ice pack for 5 to 10 minutes to help slow the bleeding
• If oral bleeding occurs, increase the frequency of mouth care
• If blood is in vomitus, take your prescribed antiemetics, antacids, or medications to decrease acid in the stomach; avoid spicy or acidic foods and caffeine
• If blood is in urine, increase fluids; note color and amount of urine for reporting to your doctor
• If bleeding vaginally, note if the bleeding is heavy or abnormal and the size of clots; do not use tampons; keep track of how many sanitary napkins are used for reporting to your doctor

Constipation is a very common problem for our patients. Pain medications, chemotherapy drugs, erratic diets, pain, and a patient's emotional state may all contribute. Management of this problem is simple but usually requires continuous rather than intermittent treatment. Below is a standard prescription that works well for most people to result in a regular bowel movement (BM).

1. Stool Softener (Senokot, Colace, Docusate Sodium, Surfak) -Start by taking two pills daily, every day, then adjust your dose gradually up or down until you have a good BM every 1-2 days. Some patients will need as many as 4-5 pills twice daily. If bowels get loose, stop taking pills until bowels firm up, then start again at a lower dose.



2. Milk of Magnesia (MOM) or Haley's MO -Take two tablespoons twice daily if you didn't have a good BM the day before. Some people will need this frequently, others rarely or never.



3. Dulcolax tablets or suppository -This may be tried once or twice if there are no results from Step 1 and Step 2. These should be used sparingly.



4. Lactulose, Chronulac, Magnesium Citrate, Fleet's Enema - these should only be taken on Doctor's Orders.

Of course, eating a diet rich in fresh fruits, vegetables, fiber-containing cereals, and getting daily exercise often will result in regular bowel function.

The following treatment plan is primarily for diarrhea caused by chemotherapy. Please talk with your doctor about treatment for other causes.

1. Avoid milk, dairy products, and citrus juices (citrus irritates stomach linings). In addition, fatty foods (hot dogs, pizza, bacon, fried foods, and gravies), foods that contain lots of fiber (whole wheat bread, bran, nuts, popcorn, seeds) or foods containing caffeine (coffee, tea, colas, Mountain Dew, chocolate) can also make diarrhea worse.



2. Do drink plenty of clear liquids, especially water, Gatorade (which can be diluted to half-strength), and apple juice. It is often helpful to limit your diet to clear liquids for 12-24 hours, or until diarrhea stops, then gradually add clear soups, bread, and crackers. Once these stay down you can gradually resume your normal diet.



3. Imodium AD -This over-the-counter pill is useful to slow down diarrhea. Follow these instructions instead of the instructions on the box.
   
   -Take one pill after each loose BM (If BM's are not loose or watery, do not take Imodium).
   
   -You can take as many pills a day as you have loose BM's. If you are having more than ten BM's daily, call the nurse at your primary office.
   
   -Stop taking Imodium when BM's are down to one or two daily, or when they begin to firm up. You can make yourself constipated if you take Imodium past this point.



4. Lomotil -This prescription medication is a little more potent than Imodium. If Imodium is ineffective, call the nurse at your primary office for a prescription. The directions are exactly the same as for Imodium.



5. If the above are ineffective you need medical evaluation and more potent medications. Patients who become dehydrated from rapid fluid loss may need hospitalization. Call the nurse at your primary office to come to the office for evaluation and treatment. If it is after office hours or on a weekend, call your primary office and ask the answering service to call the nurse practitioner or MD on call to call you back for further instruction. If you have no answer in 30 minutes, please call again.

Mucositis, or stomatitis, is a medical term that refers to the mouth sores and inflammation caused by some chemotherapy drugs. Some drugs, especially 5-FU and methotrexate, frequently cause this. Others, such as Taxol, Taxotere, Adriamycin, and Doxil, may cause mucositis in some patients. The severity of mucositis varies considerably. Some patients with mild sores simply have discomfort when eating. More severe mucositis can prevent any oral intake and lead to dehydration. Since the same chemo drugs that cause mucositis may cause diarrhea, patients with both of these problems may become dehydrated quickly. The following treatments may help to ease the discomfort of mucositis. However, once mucositis has started it simply takes time (a few days) to resolve.

1. Step 1. Keeping ice in your mouth during an infusion of 5-FU can reduce the severity of mucositis.



2. Step 2. Rinse your mouth frequently with a solution of two teaspoons baking soda in a cup of water. This should be repeated every 2-4 hours. Be sure to spit it out; do not swallow it.



3. Step 3. Avoid citrus juices, over-the-counter mouthwashes, hot or very cold foods, and spicy or salty foods.



4. Step 4. "Ron's Rum" - this prescription anesthetic mouthwash can ease pain and allow you to eat or drink after using it. Ask your doctor or call the nurse at your primary office for a prescription.



5. Step 5. If you see white patches in your mouth you may need a special antibiotic for yeast (thrush) infection. Call your primary office and talk to the nurse.



6. Step 6. If you cannot eat or drink, call the nurse at your primary office for instruction or to be seen by a doctor. You may need to get IV fluids or more potent pain medications

Most chemotherapy drugs can cause a decrease in the white blood count, or neutropenia. When a patient's white blood count is low there is increased susceptibility to infection. Moreover, an infection, once started, can spread rapidly because the body's defenses are decreased. The white blood count generally reaches it's lowest point, or nadir, between one and two weeks after the chemotherapy is given, then gradually rises toward normal . This is why doctors often check blood counts between cycles of chemotherapy and before the next cycle is given.

It is important to contact a nurse or doctor at your primary office if you develop temperatures to 101 degrees, sweats, shaking chills, or other signs of infection between cycles of chemotherapy. We will usually have you come to the office to check blood counts and be evaluated by a nurse practitioner or doctor. Depending on the blood counts and exam a decision will be made whether to admit to a hospital, treat as an outpatient, or simply observe.

When a patient has a low white blood count, or if the patient's doctor expects this to occur after chemo, the patient is often started on Neupogen (GCSF) or Leukine (GMCSF) shots, which stimulate cells in the bone marrow to produce more white blood cells. These drugs are generally given for several days in a row at the nadir. Patients are generally started on antibiotics when white blood counts are low. Cultures of blood, urine, catheters, ports, or any infected sores may be done to help direct antibiotic therapy. If a patient is very ill or if the white blood count is very low the doctor will often advise admission to a hospital.