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9/17/2021

Chemotherapy, Part 1

Season 1, Ep. 3

Welcome to the Ovarian Cancer Education Podcast, a podcast centered around a cancer diagnosis and what that means, a podcast created to help physicians and patients learn from each other, connect, and share stories and knowledge. Today’s episode will focus on treatment options for ovarian cancer.
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Vanessa:
Welcome to the Ovarian Cancer Education podcast, a podcast centered around a cancer diagnosis and what that means. A podcast created to help physicians and patients learn from each other, connect, and share stories and knowledge. This is the first part of a two-episode podcast on chemotherapy. The second episode, which focuses specifically on side effects, is being released at the same time and can be found at any major podcast app, or at www.ovariancancerpodcast.com. I’m Vanessa and I’m joined today by my guest moderator, Rachel.

Rachel:
Thanks, Vanessa. Hi, I’m Rachel.

Vanessa:
We touched on chemotherapy a bit in our treatment options episode, but this time we’re focusing on just that. We’re going to talk to an ovarian cancer survivor named Eva, and we will also be joined by Dr. Anna. Hoekstra, a gynecologic oncologist at the West Michigan Cancer Center in Kalamazoo, Michigan, and Dr. Catherine Christen, a clinical pharmacist who specializes in oncology pharmacy at Michigan Medicine in Ann Arbor, Michigan. They’ll help us understand a bit more about chemotherapy, and Rachel and I will help fill in the gaps.

Vanessa:
If you’re listening to this podcast, there’s a good chance that you or a loved one have been diagnosed with ovarian cancer, which can be a scary and an uncertain time. This podcast will help provide information and insight, but there are a wealth of other resources out there for you, and we’ve included some of those resources in the show notes for this episode.

Vanessa:
We have also helped develop a patient navigation line with the state of Michigan, to help patients find gynecologic oncologists. The phone number for that line is 1-844-446-8727.

Vanessa:
Just as a starting point, it’s really important to realize that the experience of chemotherapy is completely different for every patient. No two patients experience chemotherapy in the same way. It’s about biology and what makes their body different from all of the other bodies. One patient might experience a really extreme side effect and another patient on the same drug or for the same cancer might not experience that side effect at all.

Rachel:
And it’s impossible to know beforehand.

Vanessa:
Right. So Eva’s story will act as a guide for us, and Dr. Hoekstra and Dr. Christen can help us understand some of the other things they’ve seen people go through. But if you’re listening to this and something you’ve experienced isn’t covered in this episode, communicate with your doctor’s office.

Vanessa:
Before we jump into the details, let’s let Eva tell us a little bit about her experience with cancer.

Eva:
I’m not sure where to begin about my experience with cancer. It started late July, 2020. It was kind of weird. Who gets a cancer diagnosis in the middle of a pandemic? So that was strange. But I was having some abdominal discomfort and tried to get in to see my primary care doctor, couldn’t, and they referred me to a walk-in clinic.

Eva:
So I did that and there was a nurse practitioner in there who I was familiar with. I thought I had a UTI, and she wasn’t quite so sure. She kind of thought kidney stones. So she gave me an antibiotic and said, if you’re not feeling better in 48 hours, I want you to go to the ER. And I ended up in the ER, two days later, like she said. And she probably saved my life by telling me that.

Eva:
And I had a MRI, an internal ultrasound, and a CT scan, all within four hours, and was told I had a 13 centimeter mass in my uterus. And it just went from there. I went to a local gynecologist two days later; it was a Friday. The following Friday I was in seeing the oncologist. And 10 days later I was in surgery. That was my first experience with the C word.

Rachel:
Not a lot of time to mentally prep.

Vanessa:
No, a very scary experience, both surgery and chemotherapy treatment. And the pandemic made that worse for Eva.

Eva:
I think the scariest part before treatment was just hearing that word. And you had to go through everything alone, again, because of the pandemic. Doctors don’t want visitors in there with you at first. I was not concerned about having surgery at all. I had a lot of faith in my oncologist surgeon person, and I knew he’d do the right thing, and I knew this had to come out quickly. So, that was probably the scariest part. The most daunting part was facing chemo. That worried me more than surgery.

Rachel:
I think that would be the part that would worry me the most, too. You hear so many stories about chemotherapy.

Vanessa:
Let’s let Dr. Hoekstra define it for us as a starting point.

Dr. Hoekstra:
Chemotherapy is medicine given to patients with cancer to either control cancer growth or to kill cancer cells.

Rachel:
She called it a medicine, but I’ve heard it’s sort of a poison and that’s why it kills cancer cells, but also makes people feel sick.

Vanessa:
Kind of. Dr. Christen explains a little bit of about that.

Dr. Christen:
Generally, most chemotherapies, if a cancer cell is sensitive to it, are designed to kill cancer cells. Unfortunately, sometimes they also can cause problems with your normal body cells, and so sometimes you can see side effects due to the chemotherapy.

Vanessa:
So yes, it does affect normal body cells too. We’ll talk a lot about side effects later.

Rachel:
But the goal is ultimately to kill the cancer, right?

Vanessa:
In a perfect world, sure. But the world isn’t always perfect. Dr. Hoekstra can tell us more about how goals can be different per patient.

Dr. Hoekstra:
There can be different goals of chemotherapy for each individual patient. For some patients, the goal of chemotherapy is to either reduce the tumor burden or prevent growth of cancer. For other patients who have significant symptoms of cancer, the goal can be to improve their quality of life by reducing fluid or reducing tumor burden, which might improve their appetite or their energy level. For most patients, the goal of chemotherapy is to increase the chances of cure, but some patients take chemotherapy to prolong their life. One group of patients that also can get chemotherapy are those who have their disease completely removed but would like to take chemotherapy to prevent the cancer from coming back.

Vanessa:
So going through chemotherapy isn’t always about a cure. It can be very valuable and successful as a treatment for other reasons, too.

Rachel:
So when do you do the chemotherapy? Is it before or after surgery?

Vanessa:
It can actually be either. Gynecologic oncologists will look at scans of the body to decide if a patient’s tumor can be removed to what’s called the optimal point, which means that there is little to no cancer left. If they think they can, they do surgery first and then chemotherapy after to sort of mop up any leftover cancer cells. That’s called adjuvant chemotherapy. If the tumor is too large or too spread out, they might do chemotherapy first, which is called neoadjuvant. Dr. Christen can tell us about that.

Dr. Christen:
So neoadjuvant is given upfront. Once it’s determined, you are a good candidate for surgery, then the surgeon takes you to the operating room and will de-bulk the tumor, hopefully to an optimal point, ideally to a point where there is no visible evidence of cancer left in your abdomen. Then usually because we know that there’s always some stray cancer cells left behind, we usually follow up with some additional chemotherapy, especially if you’ve only had three or four cycles. And typically, we like to give at least six cycles total for treatment.

Rachel:
Okay. So just to make sure I got that. If the tumor is small enough, surgery first and chemotherapy after. If the tumor is too big or too spread out, some chemo first, surgery second, and then some chemo after?

Vanessa:
Yes.

Rachel:
How quickly after surgery does the chemotherapy start?

Vanessa:
Dr. Hoekstra can help us with that.

Dr. Hoekstra:
Patients usually start receiving chemotherapy very quick after surgery, typically within three to four weeks. Many times, they’re still recovering from the surgery, but it is important to start the chemotherapy quickly in order to prevent the cancer from growing back. We know that ovarian cancer specifically starts growing back very quickly after surgery, so we have seen data that supports providing chemotherapy very early in the surgical recovery in order to have the best possible chance of cure.

Rachel:
So what happened in Eva’s case with her surgery and chemotherapy?

Vanessa:
She had adjuvant chemotherapy, so surgery first and then chemotherapy after. Here’s her story.

Eva:
After my surgery, I met with the doctor. It was about two and a half weeks after. My surgery was August 17th, and I believe I met with him September 1st or 2nd. It was right in there. And he’s the one who told me that there would be the six rounds with the big drugs. He has a team set up who works with him. The nurse practitioner is the one that I see for my exams, and I talk to her with questions when I’m in there at the clinic. And he has what they call a primary nurse, and she is the one who, well, she knows all the answers to the questions, and when I had issues with chemo, she was the one I called. She always gets back with me right away.

Eva:
So she came in, she gave me a book. I don’t know if people get books, but I have my cancer folder here. And it has all kinds of questions, answers, contacts, everything. And she gave me printouts on the three drugs that would be administered to me and they listed the side effects, but she verbally sat with me and went through each one of them and what to expect. Well, I should say what could happen, because everyone’s so individual. You don’t know how you’re going to react to these things until you’re in the middle of it.

Rachel:
So she mentioned her nurse practitioner, who sounds awesome. Is it a nurse or the surgeon who prescribes chemotherapy treatments?

Vanessa:
The person actually choosing the chemotherapy drugs is always going to be a doctor. It would be either the gynecologic oncologist who performed the surgery, or a medical oncologist who specializes in chemotherapy working in partnership with the gynecologic oncologist. Those doctors work with a team of people though, including nurses, who support them. Chemotherapy that is administered through an IV needle in the arm is administered in an infusion center, usually. Dr. Hoekstra can fill us in on some of the other team members.

Dr. Hoekstra:
There are many members of the infusion center team. The first would be the registration team, who’s responsible for making sure they have all the appropriate contact information for you and the appropriate insurance information for you. Another member of the team is the medical assistant who might take your vital signs and review your medications with you. The physician may work with an advanced practice provider, so you may see on the day of your chemotherapy administration the physician or a physician assistant or nurse practitioner, or as we call them, APP’s.

Dr. Hoekstra:
The doc will likely review your laboratory work from that day. They’ll review your symptoms, make sure that everything that you need is being taken care of, and make sure that you’re feeling well enough for your treatment. You then may proceed to the infusion room where you meet with an infusion nurse who helps provide you with both the chemotherapy drugs, as well as the pre-medications and IV fluids that you may need with your treatment.

Rachel:
That sounds a little intimidating. A lot of people.

Vanessa:
Yes, but that means there can also be a lot of support.

Dr. Christen:
Sometimes patients in the waiting area or in the infusion area will talk with each other. So they may discuss their experiences and what to expect, especially if a patient is new to the infusion area and is uncertain what may occur.

Dr. Christen:
There also can be patient support groups. There are a number of them. They can either be online or face to face. And these are people with a similar type of cancer, usually with a facilitator facilitating the discussion. So patients can actually learn a lot from each other.

Dr. Christen:
And then of course your family member or friends, usually those people are very key in supporting you through your chemotherapy process, not only to drive you back and forth, but to offer emotional support through the treatment.

Rachel:
So you said earlier that in an infusion center, it’s administered through an IV needle in the arm. Are there other ways?

Vanessa:
There are a variety of ways, but that’s still the most common. Dr. Hoekstra can give us the full overview.

Dr. Hoekstra:
There are three different ways we can administer chemotherapy. One is in the form of pills, pills that can be taken once or twice daily, and taken on a daily basis. The second way is through the veins, which could mean through a peripheral IV in the arm, or through a port. The third way that we give chemotherapy sometimes for ovarian cancer is in the interperitoneal cavity. It’s usually given through a port in the abdominal wall and delivered directly into the abdominal cavity.

Rachel:
Directly into the abdominal cavity? How is it decided which method they’re going to use?

Vanessa:
Dr. Hoekstra explains that there are studies that help determine that and it changes as medical research advances.

Dr. Hoekstra:
Different patient situations can require different methods of administration. There have been studies done for patients in different stages of disease that show that chemotherapy delivered through the interperitoneal cavity, for example, might be more effective under certain clinical circumstances than intravenous chemotherapy. And in some circumstances, patients can be delivered chemotherapy orally that works to attain a certain goal for the patient’s care, such as prolonging their time in remission. So there’s always new data coming out and the physician teams will evaluate that data and advise patients depending on their specific clinical circumstance, meaning their stage, how sensitive they are to chemotherapy, their surgical outcome, and several other factors.

Rachel:
What happened with Eva’s chemotherapy? How did she have to have it administered?

Eva:
The only thing to administer the chemotherapy that I’ve been through, it’s been intravenously. The chemo nurses … I’m not sure if I should use this word, toxic chemo. The first six treatments were the big ones, and they were eight hour days sitting in that chair, six times. And they would find a vein in my arm and would do it that way.

Eva:
When I went on maintenance chemo, the first week in January this year, the nurses were telling me, your veins aren’t doing well here, and you’re going to have issues if we continue to do this, because I have to have 17 rounds of maintenance chemo at this point. So I did have a port installed, for lack of a better word. And it was only a three-hour procedure, not bad at all. And I’ve had two treatments now through the port, and it is easier, I’ll say that.

Rachel:
What’s a port?

Vanessa:
It’s a small device with a tube that attaches to a vein. It means that when patients go in for their chemotherapy appointments, they don’t need to get stuck with a needle every time. The infusion center team can use the port that’s been implanted.

Rachel:
How long do they last?

Vanessa:
Great question. Let’s ask Dr. Hoekstra.

Dr. Hoekstra:
Ports can last for a lifetime. If they get regular maintenance with flushing and aspirating, or if they’re used frequently, they can last for a very long time. Occasionally they can get infected and need to be removed, or they might get a clot around them and need to be removed, but for most patients, they function very well and are not a bother.

Rachel:
So I’ve heard words like regimen, cycle, and course in relation to chemotherapy. Can we talk about what each of those means?

Vanessa:
Definitely. Let’s ask Dr. Hoekstra again.

Dr. Hoekstra:
A regimen of chemotherapy drugs is a set of drugs given at specific intervals. So it may be one, two, or three medications given any time between daily to weekly to monthly, but a regimen is the choice of drugs.

Dr. Hoekstra:
A cycle is one unit of chemotherapy. Many times it’s three or four weeks in length, and there can be one chemo infusion during that cycle or multiple infusions, depending on the regimen that’s chosen.

Dr. Hoekstra:
A course of chemotherapy is the recommended number of cycles of a specific regimen of drugs. So for example, you may get a recommendation for six cycles of a two drug combination drug regimen, and that would be a single course of chemotherapy.

Vanessa:
So each visit to the infusion center is considered an infusion or a treatment, and you can have multiple treatments within a cycle.

Rachel:
Okay, I understand. How long is each treatment?

Vanessa:
It can vary, but it can take five to six hours.

Rachel:
Quite a while.

Vanessa:
Yes. In the next part of this episode, Eva tells us that she brings magazines with her. It’s good to bring along something to do to entertain or distract yourself.

Rachel:
Should patients do anything to prepare before an infusion?

Vanessa:
That’s a really good question, thank you. There are some things.

Dr. Christen:
Oh, one comment that I want to make about all of your other medications. You want to take all of your other medications before your chemotherapy infusion, such as your blood pressure medication, your cholesterol pills, your diabetes medications.

Dr. Christen:
You also want to eat before your infusion, and in fact, you can always eat before any of our blood work. We’re not checking your cholesterol level where you would have to fast. So we do see that happen where people come in and they’ve driven for a couple of hours and they have not eaten breakfast. You want to just eat lightly. You don’t want to eat anything very heavy. You want to eat cereal, toast, english muffin, poached eggs. You don’t want to eat bacon and eggs and a real greasy breakfast, but you want to eat just lightly. Or a sandwich or soup for lunch. But you can always eat before our chemotherapy, and you want to take all of your regular home medications.

Vanessa:
Dr. Christen also has some advice about getting to the infusion center.

Dr. Christen:
The one thing that I would caution people, just because of the drugs that we give in the infusion center, that you should not drive home. Some of our pre-medication that we give can slow reaction time down, such as Benadryl or diphenhydramine, that might make you a little sleepy. The Taxol actually is dissolved in a couple of solvents. One of the solvents is alcohol, like drinking alcohol, so if you’re not used to drinking, you may be a little buzzed on the way home, and we don’t want you to be pulled over for driving under the influence. The other solvent is Cremophor, which is keeping the Taxol in solution, but also the Cremophor can increase risk for allergic or infusion reactions. That’s one of the reasons we’re using antihistamines ahead of time, to try to prevent these allergic or infusion reactions.

Rachel:
And what about when you get home?

Vanessa:
Dr. Christen has run into some of those questions from her patients too.

Dr. Christen:
Well, one of the questions that does come up are pets as well as small children. Pets, I think it really depends on the pet. As far as cats, where it’s an indoor cat, I always tell patients if the cat has claws and scratches you, you should wash the scratch with soap and water because there’s a lot of stuff under cats, claws, and we don’t want you to develop a skin infection along the lines of the scratch. I also tell people if their cat uses a litter box indoors, they should have someone else change the litter box. So most patients are quite pleased about that, if that’s sort of a distasteful task for them.

Dr. Christen:
As far as petting your cat or your dog, I see nothing wrong with that, and they can be a source of comfort. So I think pets are perfectly okay, but I do put some limits around cats as far as scratches. And very rarely a dog will scratch or bite. I mean, that’s very unusual, but if that happens, you always want to just really wash out the scratch or cut as much as possible.

Dr. Christen:
As far as small children, the one limit I put on is that you probably shouldn’t be changing the diaper. And if a kid is going to daycare, you really just need to be mindful of infections, because they are being exposed to a number of households in daycare, or even in school, if they’re going to classroom classes. So if a kid is sick, I think you need to put some distance between you and the child, but other than changing diapers, I see nothing wrong with you being around a child. You are not dangerous to a child because you have chemotherapy inside your body and that you may be slowly eliminating it over time. You’re not going to provide in danger to them, but because of infection, they may be a risk for you. But that really is with anybody that is actively sick, whether it’s an adult or a child.

Vanessa:
And one final thing for this part of our chemotherapy topic.

Dr. Christen:
One of the things that our pharmacists are very helpful for is looking for potential drug interactions. And some of our vitamins, especially very high doses of vitamins, can interfere with the effectiveness of chemotherapy. So I try to limit people as far as vitamin C, taking 500 milligrams or less per day, or vitamin E, 400 units or less per day, because these are antioxidants. And a lot of our chemotherapy drugs work by generating oxygen radicals to kill cancer cells, so if you’re taking high amounts of vitamin C or vitamin E, that could potentially be counterproductive to the chemotherapy.

Vanessa:
As a reminder, this is the first part of a two episode podcast on chemotherapy. The second episode, which focuses specifically on side effects, is being released at the same time and can be found at any major podcast app or at www.ovariancancerpodcast.com.

Vanessa:
We hope this helps you feel like you’re not alone and that there are resources available to you. We don’t want to scare you. We’re just hoping to shed some light on issues that some patients experience to help educate and support. Remember that your physician’s office is an invaluable resource for you. They’re there to help and support you and it’s okay to ask for that help. As we find or develop resources, we’ll continue to list them in our show notes. Thank you again for joining us.

Vanessa:
The information contained herein is information only. Users are solely responsible for all medical care and services delivered to their patients and all decisions related to such medical care and services. Neither Moxie, nor the regions of the University of Michigan, shall be responsible for any delivery of medical care or other services to any patient or any decisions, acts, or omissions of persons in connection with the delivery of medical care or other services to any patient.
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[av_toggle title=’Show resources:’ tags=” custom_id=” av_uid=’av-2cybh9′]
Michigan Dept. of Health and Human Services (MDHHS) Ovarian Cancer Patient Navigation Line:
1-844-446-8727
https://www.michigan.gov/mdhhs/

Society of Gynecologic Oncology: Ovarian Cancer
https://www.sgo.org/patient-resources/ovarian-cancer/

Foundation for Women’s Cancer: Ovarian Cancer
https://www.foundationforwomenscancer.org/gynecologic-cancers/cancer-types/ovarian/

NCCN Patient Guidelines: Epithelial Ovarian Cancer
https://www.nccn.org/patients/guidelines/content/PDF/ovarian-patient.pdf

American Cancer Society: Ovarian Cancer
https://www.cancer.org/cancer/ovarian-cancer.html

Center for Disease Control and Prevention: Ovarian Cancer
https://www.cdc.gov/cancer/ovarian/index.htm

Clinical Trials
https://clinicaltrials.gov/

Facing Our Risk of Cancer Empowered (FORCE)
https://www.facingourrisk.org/

Michigan Oncology Quality Consortium
https://moqc.org/

Michigan Ovarian Cancer Alliance (MIOCA)
https://www.mioca.org/

National Ovarian Cancer Coalition (NOCC)
http://ovarian.org/
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DISCLAIMER
The information contained herein is information only.  Users are solely responsible for all medical care and services delivered to their patients and all decisions related to such medical care and services.  Neither MOQC or the Regents of the University of Michigan shall be responsible for any delivery of medical care or other services to any patient, or any decisions, acts or omissions of persons in connection with the delivery of medical care or other services to any patient. These materials were made possible by a generous grant from the Michigan Department of Health and Human Services.
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