The following excerpt is taken from Chapter
of Colon & Rectal Cancer: A Comprehensive Guide for
Patients & Families by Lorraine Johnston, copyright 2000 by
O'Reilly & Associates, Inc. For book orders/information, call
(800) 998-9938. Permission is granted to print and distribute this
excerpt for noncommercial use as long as the above source is
included. The information in this article is meant to educate and
should not be used as an alternative for professional medical care.
People can have a wide range of responses to chemotherapy, even if
they're receiving the same drug and dose. You don't know for certain how
you'll respond, so it would be best to make sure you have certain supplies
and assistance if you need them. Some of the drugs given for chemotherapy
or to prevent side effects can cause drowsiness or affect concentration,
for instance, or you might be sitting for many hours in a room that is
overly warm or too cool.
My advice is to begin receiving treatment with an open mind and the
attitude that you will have no side effects. You may not have any. I've
been on 5-FU/ leucovorin for nine months so far, and I've not had any mouth
sores. Chemotherapy is different for each patient, and sometimes each
treatment is different. My experience is that my first few treatments were
without any side effects at all. As I continue (I have it every other
Thursday) sometimes I have what I call chemo sickness. I just feel bad, no
vomiting or trots to the bathroom as some patients have, I just feel tired
and don't want to do much. I don't always get those feelings, and
oftentimes when I do, I force myself out of the house and mow the lawn or
get busy with something to take my mind off how I'm feeling. It really
works for me.
For these and other reasons, during your first treatment visit it would
be wise to have a friend or loved one along, not only for emotional
support, but to handle issues such as safely tucking away written
instructions for diet and aftercare; understanding and remembering verbal
instructions; communicating insurance information; handling the co-pay, if
any; and assisting with the drive home. As you adapt to treatment, you may
need someone to drive if you take medication for nausea before leaving
home, as many of these drugs cause drowsiness.
Comfort should be high on the list of priorities for anyone facing
chemotherapy. Come prepared for a few hours' testing or treatment by
wearing comfortable, layered clothing; bringing relaxing buddies or music
cassettes; and asking in advance what to expect. Don't arrive with an empty
stomach. Eat light food up to two hours before treatment.
I experienced many of the side effects of chemotherapy: mouth ulcers,
nausea, vomiting, fatigue, a metallic taste. But there were medications to
counteract these problems. We had to try more than one, but finally hit on
a combination of Zofran/Decadron drip with Phenergan pills. By mid-week a
shot of Ativan IV was added for nausea. That really worked well. My dentist
prescribed a mouth rinse of Triamcinolone mixed with water and absolute
alcohol that really numbed it.
I completed my chemotherapy a week ago. I have a glorious five weeks off
before beginning Camptosar for added protection, as I am at high risk for
future pelvic recurrence.
Although the antinausea drugs in use today are excellent, store a bucket
in your car against the possibility of nausea during the ride home. Call
the doctor a day or two in advance to get nausea medications, and take them
beforehand if instructed to do so.
Before your initial treatment, ask about wearing cosmetics, jewelry, or
nail polish, because skin and nail bed color are useful ways for the
medical staff to assess your well-being and response to drugs. Ask about
using lotions or aftershave, as these may cause skin irritation depending
on the treatment being given. If you feel strongly about wearing cosmetics
and nail polish to treatments to improve your frame of mind, ask them about
a compromise, such as leaving one fingernail bare for visibility or for
using the thimble-like oxygen sensor that slides over your finger.
Ask if your chemotherapy will be administered into an arm vein. If so,
plan to wear a short-sleeved top, and bring a cardigan for the parts that
needn't be uncovered and might get chilled.
Tell the staff about dental appliances, contact lenses, surgical
staples, pacemakers, and other manmade materials that may interfere with
Certain drugs used for chemotherapy may react badly with certain foods
or food supplements. Ask your doctor if you should avoid certain foods such
as grapefruit for a week or two before or after treatment, as grapefruit
interferes with metabolism of some drugs by the liver. Vitamins,
antioxidants, or supplements should also be approved by your doctor before
use. Potassium supplements may trigger a dangerous metabolic imbalance,
tumor lysis syndrome that imperils the kidneys if you have a large tumor
that is killed rapidly by treatment.
You may also receive instructions about avoiding other possibly
dangerous circumstances such as excessive sunlight or crowds. Some of the
drugs used for colorectal cancer cause skin to become overly sensitive to
sunlight. Protective clothing, sunglasses, and sunscreen lotions may be
The schedule on which chemotherapy is administered is based on years of
research that determine a drug's effectiveness at a certain dose and
interval. Some chemotherapies are given daily; some are given weekly for
several months; some are given once a month for many months. Those
delivered via portable pumps may enter the body throughout the day for many
days. Oral medications taken at home may be taken once a day or several
times a day.
If you can't afford or don't want to miss time from work, you might
prefer scheduling your treatment to occur just before the weekend so you'll
have a couple of days to adjust and recover without the additional stress
of meeting work responsibilities.
Don't be surprised if the schedule on which your chemotherapy is
administered differs from the schedules you hear others discussing, because
your schedule is likely to be tailored to your particular circumstances.
You may, for instance, be receiving a drug that might be toxic to the
heart, but on a less condensed schedule that is intended to lessen
Depending on what drugs are being used, the timing of subsequent therapy
may be influenced by the quantity of blood cells remaining in your
bloodstream after your last treatment. Thus, for certain regimens, your
blood will be tested when you arrive (or perhaps a few days in advance, if
your doctor recommends or you prefer) using a standard measurement known as
a complete blood count, or CBC. If your blood counts are too low, treatment
may be delayed a few days or a week.
A delay of one week is not likely to affect the success of treatment,
but a great many delays, or a delay of long duration, may. For this reason,
oncologists sometimes prescribe either blood transfusions or injections of
colony stimulating factors to bring your blood counts up to safe levels.
Colony stimulating factors are manmade copies of natural body products that
cause bone marrow to produce more new blood cells than it otherwise
Shelly describes how important it is to get treatment on schedule:
Just the other week I had a cold, but had chemotherapy anyway. I spent one
whole day in bed sleeping. In general the 5-FU/ leucovorin infusion knocks
me down for at least two full days. It's something I've learned to expect
after chemo. I guess I will never get really used to it.
I've just learned to tolerate it and look forward to tomorrow which can
always be better. Keep up the spirits and the attitude, the rest will be
For therapy administered from an IV bag or syringe rather than by
infusion pump, it's not unusual for one chemotherapy session to last for
several hours. High-dose therapies that must be administered over several
days (with or without stem cell rescue) may require a hospital admission,
but the trend is toward outpatient treatment for all but the most rigorous
procedures or the sickest patients.
Often, your treatment is not started until a doctor, nurse, or medical
technician has weighed you, taken your blood pressure and temperature, done
a brief physical, asked you about symptoms and side effects, and drawn
blood to check blood counts.
If you have a portable pump, however, you might simply be examined,
refilled, and discharged.
Your first visit is a good chance to begin to make friends with the
nursing staff. Oncology nurses are a unique breed, generally cheerful and
unusually kind. Often they'll have great ideas for helping you that might
not occur to your doctor to mention, such as where to buy satin pillow
covers to reduce hair loss. Interaction with a good nurse may well be one
of the finest and most rewarding experiences in life, exemplifying the best
that humans can offer each other. Many oncology nurses say that they get
much more from their patients than they give.
You may find as well that your fellow patients in the waiting or
treatment areas have good insights to share about experiencing
chemotherapy. Often, those waiting in an oncologist's office are reluctant
to start a conversation with others because the people nearby seem very
worried or withdrawn, or because they themselves have so much mental and
emotional processing underway. You might find, though, that deep and
instructive friendships are formed among cancer survivors in this
After you're settled in the treatment area, waiting or being treated,
consider having your companion visit the pharmacy to buy ice bags or a pill
organizer, fill any prescriptions, or buy any over-the-counter drugs,
including stool softeners and anti-diarrheals, that you'll need later. With
this arrangement, if you feel bad or fatigued after treatment, your
medications and supplies will be immediately available.
Chemotherapy may be administered in a doctor's office, in a hospital
outpatient setting, or, if given in the form of tablets or a portable pump,
actively or passively in your home. If it is administered in a doctor's
office or outpatient department, it may be administered by a chemotherapy
nurse or by the doctor. It may be administered in a large room with other
cancer patients who are seated in reclining chairs in partitions divided by
curtains, or it may be administered on a bed or chair in a private
Sometimes the setting in which chemotherapy is given is dictated by what
insurance companies will pay for. Injections of colony stimulating factors,
for example, which may be necessary to stimulate bone marrow, may be
administered safely and easily by the patient or another at home. Some
insurance companies, however, will pay for these injections only if they
are administered by a doctor.
Some chemotherapies and some tumor types are known to be associated with
risks that are best handled in a hospital setting. Cyclophosphamide
(Cytoxin), for example, is known to damage the bladder, and is best
administered simultaneously with heavy bladder irrigation such as that
provided by intravenous fluids. Large tumor masses of the chest or abdomen
that die quickly when treatment is started may require IV fluids to protect
the kidneys only at the start of treatment. For this reason, you may be
admitted to the hospital to receive these treatments.
To tell you the truth, so far the chemotherapy has not been bad. I've only
just had my second week of it, but I look at it this way: At the end of
each week, I get to go into a quiet, peaceful room, read a good book, watch
Oprah if I desire, suck on ice chips and 7-Up, and even call a friend on my
cell phone if I feel so inclined, while my combination of 5-FU and
leucovorin drips into my veins. Okay, okay ... I will admit I had a small
bout with diarrhea when I got home last evening, but nothing to complain
about. For me, I think I made the right decision to have chemotherapy, and
a positive attitude makes it all the easier.
There are several different forms of chemotherapy for colorectal cancer,
and different ways to administer it.
Portable (Ambulatory) Pumps
Some studies have shown that, for certain patients, a continuous
infusion of anticancer drugs for colon and rectal cancer is more effective
than a single weekly administration. By using a portable infusion pump,
it's possible to have certain anticancer drugs administered throughout the
day for many days, or to have multiple drugs delivered at the same time.
These pumps can be programmed to deliver, or not deliver, a steady or
varying dose of drugs for hours, days, or weeks.
If you have a venous access device such as a central (chest or neck)
catheter or a peripheral (arm) catheter, most likely it can be used for
delivering drugs via portable pump. If you don't have a venous access
device, almost certainly one will be put in place before treatment starts.
A very small battery-powered pump--about the size of a paperback book--is
connected to this line. The pump can be implanted under the skin, or
carried in a satchel that you can wear around your waist or over your
I am 72, and am in the sixth week of a six-month course of continuous
infusion of 5-fluorouracil and leucovorin. I had a hemicolectomy three
months ago; I was diagnosed as stage III with two of 35 nodes containing
tumorous tissue that had spread, but no other metastases were detected.
My 5-FU is infused continuously 24 hours a day through a Mediport
implanted in my chest and powered by a battery-operated pump contained in a
fanny pack weighing about 1-3/4 pounds. It's a nuisance I've gotten used
to, and I have no trouble sleeping, driving, shopping, working in my shop,
showering, and so on. I get new batteries, a 5-FU refill, and a dose of
leucovorin every Wednesday at the USCF/Stanford Oncology clinic. So far,
the entire process has been completely painless and I've had no nausea or
diarrhea. The only side effects have been a painless rash on the backs of
my hands and some irritation in my windpipe during week four. Every week of
continuous infusion is followed by one week off.
I definitely recommend my Mediport central catheter rather than a PICC (
peripherally infused central catheter) line, although the Mediport was more
expensive and required a surgical procedure for installation.
Portable pumps also can deliver drugs under the skin or directly into
the abdominal cavity, but delivery via a vein or directly to the liver via
the hepatic artery is most common.
The advantages of a portable continuous infusion pump are:
- The possibility of a better anticancer response to chemotherapy.
- Fewer and shorter doctor visits, yielding less disruption to your
- The possibility of greater side effects with continuous infusion,
entailing a temporarily reduced quality of life.
- The inconvenience of having to adjust to and carry an attached pump all
- The need to have a venous access device put in place.
- If an implanted pump is used, it might need to be put in place while
you are under general anesthesia.
Implanted and portable pumps have advantages and disadvantages as well.
Implanted infusion pumps might be more expensive and require a surgery to
implant, but are less likely to clot or become infected as a central venous
catheter might when it is attached to an external pump.
The reservoir in your pump can be refilled weekly or on some other
schedule determined by your oncologist. Implanted pumps might be accessed
through the skin; external pumps and balloon reservoirs might just be
There are several kinds of portable infusion pumps, and many different
regimens for delivering drugs at optimal levels. A search of the medical
literature reveals some of the techniques attempted by various researchers
in the last few years. These examples are given so that you'll be aware of
this variety of approaches, and so that you'll have less concern if you
hear of someone whose treatment schedule or pump type is different from
- A 60-milliliter reservoir pump with variable flow rates of 2, 6, 8, or
12 milliliters every 24 hours, and refilled weekly.
- An implanted reservoir giving low-dose infusion over six to seven days
for several months to two years, using balloon-style continuous infusion.
Access to the body was via central venous catheter, aortal infusion, or
- Two disposable balloon pumps connected to an implanted pump via a
central venous catheter.
- A pump connected to the hepatic artery via a prior surgery delivering
first floxuridine continuously for seven days, and followed by a weekly
one-dose pump of 5-fluorouracil for three weeks.
- Continuous infusion via portable pump for 21 days, ceasing for 7, and
repeated every four weeks.
- Prolonged infusion for six weeks with a one-week rest period.
- Continuous infusion for five days, followed by weekly one-hour
intravenous infusions, all for seven weeks.
- Continuous infusion for five days, followed by five-minute intravenous
injections on days 12 and 19.
Chemotherapy for colorectal cancer often is administered once a week
into a vein using a temporary or semi-permanent IV line in the forearm, or
by any one of a number of venous access devices (VADs), such as a central
catheter that has been implanted into a large vein in your chest.
If you experience trouble with inaccessible veins, or if they worsen
during treatment, discuss with your doctor the advantages and disadvantages
of venous access devices such as central catheters.
Some of the drugs used will be in plastic bags that are hung from your
IV pole. They may be mixed with a saline drip to dilute them as they enter
your vein. Others may be injected directly into your IV line from a large
syringe. This method is called a bolus push.
Some drugs used for intravenous chemotherapy are damaging if they come
in contact with skin. Notify the medical staff immediately if you
experience any pain, swelling, redness, or burning near the injection
You may feel a warm flush when certain drugs are administered. Verify
with the medical staff that this is normal for your drug regimen.
My husband had severe sweats during the administration, and so took
atropine about 30 minutes into treatment, and again an hour later. This
helped with the sweats and with immediate onset diarrhea.
Monoclonal antibody therapy
Monoclonal antibodies are a manmade version of a natural body product
secreted by our white blood cells. They are injected into a vein via an IV
line or catheter.
It's possible to have an allergic reaction to monoclonal antibodies,
because often they are formed from combined human and mouse antibodies.
This is a very common reaction that is easily controlled, but it must be
addressed immediately to keep it from becoming serious. To avoid this
allergic reaction, antibodies usually are injected very slowly over several
For a few subtypes of colorectal cancer that escape from the primary
tumor site and spread along the lining of the abdomen, injections of
chemotherapy directly into the abdominal cavity, called the peritoneal
cavity, might be used.
Intraperitoneal chemotherapy requires access to the peritoneum. Access
is achieved in one of two ways:
- Implanting of several tubes and drains during the surgery to remove the
tumor, or during a subsequent surgery
- Insertion of a catheter each time the treatment is given
Once tubing and drains are in place, the administration of anticancer
drugs may begin as early as during surgery and may continue for five days
beginning the day after surgery while you remain hospitalized. Typically
thereafter, cycles are repeated for five days of each month for several
months. The drugs are infused, left in place for almost 24 hours, then
The medical staff administering the chemotherapy also may do imaging
studies such as CT scans during or after infusion to be sure that all areas
of the peritoneum are exposed to adequate amounts of anticancer
Hepatic artery infusion (HAI)
Hepatic artery infusion is the delivery of large doses of chemotherapy
directly to the liver, either as a multi-hour dose during surgery or in the
doctor's office, or at home via a portable infusion pump. When it is
administered in the doctor's office, your experience will resemble that
described previously in the section called "Intravenous therapy,"
whereas administration by portable infusion pump is described in the
section "Portable (ambulatory) pumps," earlier in this
In October of 1997 I had an operation for hepatic arterial infusion.
This necessitated wearing a fanny pack whereby chemotherapy was infused
directly into the liver for two weeks, then I had a rest of two weeks off.
At the same time, I was given once a week treatments of CPT-11, 5-FU, and
leucovorin. By January of 1998, I had a 50 percent reduction in size and
number of my tumors (eight tumors averaging 5-8 cm). By April, my CT scan
showed no evidence of liver involvement.
Your chemotherapy regimen may include oral medication along with or in
place of intravenous injections, or you may be given oral medication to
offset nausea. You might be given tablets to take at home, perhaps several
times a day, or perhaps every other day. You may be given prescriptions for
anti-diarrheal or antinausea medications to take with your
Although taking pills may seem easy, there are several potential issues
of which you should be aware.
The chemotherapy drugs can cause some problems in swallowing pills.
After several days or weeks of treatment, you may notice your mouth
becoming increasingly dry as the rapidly dividing cells in your mouth die.
A good habit to cultivate is wetting your mouth before attempting to
swallow a tablet.
It's easy to forget what medications you've taken when you have quite a
few, and when some of them are making you drowsy. Each day, keep a new list
of what you must take, and check them off as you take them. Consider buying
a plastic pill organizer to assure that all doses are taken.
Colony stimulating factors such as granulocyte colony stimulating factor
(G-CSF), thrombopoietin, or erythropoietin (EPO) frequently are injected
under the skin or, less often, into muscle.
If your insurance company will pay for the drug, you may be able to give
yourself these injections at home. The medical staff will teach you the
quick, painless poke-in-the-thigh, using pinching, stretching, or slapping
to anesthetize the area first. Small syringes of the type used for insulin
usually will do; they'll give you a "red bag" for needle
disposal, which should be returned to the doctor's office when full, not
put into the trash.
If your insurance company will only pay for these injections if they are
administered in a doctor's office, you may have to make twice- or
thrice-weekly trips to the doctor.
Before leaving the doctor's office, be sure you have received written
instructions regarding any necessary dietary or behavioral changes,
information about possible side effects, prescriptions, and phone numbers
Do not leave feeling unwell. If you are feeling unwell, tell the medical
Use the restroom before leaving if you received your treatments via IV
line. Often, IV drugs are accompanied by a saline drip. The volume of fluid
that your kidneys have processed from this treatment may surprise you
Most chemotherapy treatments do not result in infection or side effects
that require hospitalization. However, occasionally such problems do occur.
Carefully note all symptoms and communicate immediately with your doctor if
If you feel inclined to do so, you can verify your chemotherapy dosage.
Most chemotherapy drug dosages are calculated based on body surface area,
but some are based on other parameters such as renal function. Keep in mind
that any variation you note may be planned deliberately by your doctor or
may vary based on how the drug is administered--that is, by IV line, pump,
or intraperitoneal infusion.
If you have a personal computer, you can access Glaxo-Wellcome's
DoseCalc web site to calculate dosages automatically given your
weight, height, and a drug name. DoseCalc also lists the current
chemotherapy regimens used against colorectal cancer, and the milligrams
per square meter needed for each drug.
If you notice a substantial difference between the calculated and actual
dose given, ask your doctor why. Often there are very good reasons for