What should I expect after CRS surgery with HIPEC?
If you receive a diagnosis of cancer of the appendix with or without pmp then you might undergo a procedure which is known as cryo-reductive surgery or CRS. This involves a thorough exploration of your abdomen for removal of tumor, mucin, intestine or solid organs such as your spleen or gall bladder. HIPEC may be recommended as an adjunct to the CRS. HIPEC involves perfusion of your abdomen with chemotherapy dissolved in a solution which is heated to 107 degrees F.
As with any abdominal procedure you can expect to experience post-operative pain. The pain medication you will receive will be unique to the institution where you had your surgery. In the hospital, you will initially have intravenous and/or spinal drugs, but over time you will transition to oral medications. Use your pain medication to make yourself comfortable and to enable you to move and walk with minimal discomfort. Try to use only as much as you need and remember that you want to be able to think clearly and get up and about.
Getting out of bed as soon as you can, walking, and deep breathing help to prevent atelectasis, (collapsing of the lung) as well as pneumonia and blood clots. With walking you can hasten the return of gastro-intestinal function. Generally when you awake from the anesthesia you will have a naso-gastric tube in one of your nostrils and fed into your stomach. This tube is put into place when you are under anesthesia. This tube helps handle the fluids of your intestinal tract until the return of its peristalsis or movement. With activity you can hasten the return of your bowel function.
This process will be marked by passing gas from your rectum or having liquid stools. Even without eating you can have liquid bowel movements. The timing of the return of bowel function depends on the amount of surgery done during the CRS and most particularly on the degree of intestine removal. When your gastro-intestinal tract starts to work, the naso-gastric tube is removed and you will be started on liquids. As you tolerate the liquids, your diet will be advanced to soft foods.
Walking also helps your circulation (particularly the veins of your legs) and helps to prevent blood clot formation. As well, you will receive blood thinners and special stockings. A pulmonary embolus, or clot to your lung, is serious and life threatening. Thus, I would encourage you to start walking or at least getting out of bed as soon as your physician says you may do so. Start with getting out of bed and sitting in a chair with your legs elevated but not crossed, to avoid clots from forming in your leg veins. When sitting is comfortable for you and with permission of your physician, start walking the halls. Start with assistance and very short excursions. As you feel better, increase both the distance and the number of walks per day. The more walking you do, the sooner you may be discharged.
When you undergo HIPEC you have had chemotherapy. Your abdomen is bathed in large volumes of solution heated to 107 degrees F. Since your abdomen has undergone trauma both from the CRS and from HIPEC, eating is a particularly difficult problem. Your medical team may be encouraging you to eat but you will find it difficult to do so. Initially very small amounts of bland food should be your diet. If you try to eat large quantities of food you might develop abdominal pain located primarily in your upper and mid-abdomen. You may feel as if you need to vomit. A reasonable starting diet, both in the hospital and continued at home, consists of oatmeal, eggs and toast, A light dinner should consist of small amounts of a protein and some steamed vegetables. Small and frequent meals work best. Drink fluids to maintain hydration. If you overeat and feel discomfort (this may also occur even if you are watchful), you must stop eating. Do not lie down flat because after HIPEC your gut does not empty normally and reflux or heartburn is common. Reflux is the movement of fluid from your stomach up to your esophagus, the fluid is going in the wrong direction. As you feel more comfortable, you can add more and varied food to your diet in a gradual manner. With these dietary restrictions, you will inevitably lose weight. While everyone on your medical team will encourage you to eat more and more in order to maintain your weight and to help in the healing process, this is very difficult to do. Expect significant weight loss. A weight loss of at least ten to twenty pounds is common. Each person has to figure out what foods are tolerable. A word of warning: do not introduce new foods when you are not near a bathroom facility. Over time, measured in months, you will stabilize and be able to maintain your new baseline weight. It takes a long time to resume eating normally as you did before surgery and to start gaining weight. Weeks to months is the usual time period. If you try to rush to eating larger meals, it might set you back. Even a year or so after surgery, you may find that eating more than your usual intake causes abdominal distress.
After any operation, weakness and fatigue are also common. However after HIPEC you probably will feel exhausted. Even if you are in good shape from having exercised prior to your surgery you will feel that you cannot do anything physical. You may sleep more than usual. It is important to resume activities but that must be done very slowly. A five minute walk on a flat surface is a good start. Once you feel that this is easy for you, increase the walk to twice a day or ten minutes. Do not try to do more than you comfortably can in an attempt to “get back to normal,” because that is counter productive. With HIPEC and even minimal CRS ,weakness and being easily fatigued is a reality. Do not push yourself too hard. Time is a great healer. How quickly you resume your work is truly dependent on how much CRS has been done. It takes a longer time to recover if intestinal work has been part of your procedure. If complications occur it will take a much longer time for you to return to full activities. Give yourself at least two months before you try to go back to work or resume full responsibilities in your home.
The physical after-effects are also accompanied by psychological effects. You have had an enormous operation. You may feel poorly and cannot fathom that you will ever get back to your “old self”. As well, the reality that you have cancer and that this is now a new life-long problem is a new reality. You may face further surgery or a round of intravenous chemotherapy. Sadness and depression can understandably occur. You must deal with your mental health because it can affect your physical recovery. There is nothing wrong with admitting that these issues exist. It is appropriate and advisable to seek appropriate help/counseling.
As discussed above, the issue of pain management is quite important. When you are discharged from the hospital, you may receive numerous pain medications. I caution you, the more prescription pain medicine you take, the harder it is to get back to your old self. At home the decisions about medication are up to you and you alone. In the hospital the frequency and dose of your pain medications are carefully regulated. These medications can affect your mental status and can contribute to sadness or depression. Moreover, starting on opiates and remaining on them for a lengthy time can lead to addiction. Each of us has a different perception of pain. However, after some two weeks post-op, the level of pain in part should be able to be handled by over- the- counter medicine. If you have significant pain after two to three weeks, consult your physician since other factors might be present to cause this continued level of pain. Remember opiates dull your mind and affect your body’s ability to function. Appropriate use of pain medications is extremely important to a faster recovery.
Please tailor your recovery to what suits you best. This explanation and these guidelines are meant only as suggestions. I hope they are helpful to you. However most of us who have had this surgery would agree with the descriptions of how you might feel after CRS surgery with HIPEC. Recovery from CRS and HIPEC may be difficult, but it is important to strive for a full recovery and a “normal” life. I wish you well.
Arthur Rettig is a retired pediatric surgeon and PMP patient himself. Despite his medical background, when first diagnosed with adenocarcinoma of the appendix, he didn’t know where to turn. Arthur was glad to have found PMP Pals on the web.
If you have questions you’d like to ask Arthur, send them to email@example.com. PMP Pals has HOPE for YOU!
We asked our PMP Pal Couples to share their “tips” for coping with the strain that cancer can place on a marriage. “Pals” Brian and Linda came forward to share their suggestions with us. About this couple:
Brian, the “PMP Pal” patient and Linda, his wife, have celebrated their fiftieth wedding anniversary! Their marriage has been punctuated by a series of challenges to Brian’s health, including the diagnosis and ongoing treatment for Pseudomyxoma Peritonei.
In today’s, article, Linda shares their “secret” of combining love and laughter, as coping tools in their arsenal against cance.
I speak from the role of the caregiver. After over 50 years of marriage to my husband, the patient, I feel I can speak fairly confidently for him. During more than half of our married life, we’ve faced medical challenges that could have brought us to the brink of utter despair. My husband has had five brain tumor surgeries for a persistent meningioma and two operations for Pseudomyxoma Peritonei.
Perhaps the most difficult time through all of these events was the clinical depression that followed my husband’s second brain tumor surgery in 1997. My usual easy going, positive outlook mate became an entirely different person. It was as if a complete stranger was living in my house, or some alien being had taken over his body. I don’t know what we would have done without our close family and our church family that simply surrounded us with love and support.
The medical “experts” have all told us that my husband is somewhat of a miracle in regards to his survival of cancer. I think that “miracle” is comprised of love, support and the excellent surgeons and medical care he has received along the way.
There is one more factor in his survival, and that is the outlook we choose to have; somehow through all of this, we haven’t lost our sense of humor. Mark Twain said: “Against the assault of laughter, nothing can stand.”
There just may be some people who are predisposed to humor and staying upbeat, and that is a saving grace. Maybe those people have not truly faced difficult situations in their lives. Perhaps however, they have, and rather than letting those situations pull them down, they choose to find ways to move forward through the pain and look for the opportunities that can arise from the challenges they face.
In 2007 when my husband’s surgeon told me that Brian has Pseudomyxoma Peritonei, I remember thinking “OK God, what is this new challenge we have to face now?”
We faced it and worked through it by still finding humor in the little things. Abraham Lincoln said “With the fearful strain that is on me night and day, if I did not laugh I would surely die.”
When my husband and I were at M.D. Anderson in Houston for a checkup following his second surgery for Pseudomyxoma Peritonei, we had some free time. We discovered a “Laughter Yoga” session that was open for patients and their families. We had absolutely no idea what this class was about, but being our usual open minded and adventurist selves, we decided to go.
We enjoyed an invigorating hour doing something completely crazy and fun. While we were laughing in this classroom with 20 complete strangers, I realized that my mood lifted exponentially, and I was thinking about nothing but laughing and the fun I was having!
Humor and laughter have always come fairly easily for both my husband and me. During our most challenging times, it has been harder to find that humor, but somehow we’ve managed to pull it out just when we need it the most.
Now, back at home in our own city, I have become a Laughter Yoga instructor, and have added this new vocation to my existing real estate career. I enjoy helping others find some time to move away from their troubles for a short period with an hour of laughter!
Faith, hope, love and laughter…these are the things that have brought us through over fifty years of marriage and a long battle with cancer!
The question I’m asked most often is, “What is HIPEC?”
Either you are a patient, relative or friend of a patient who has been diagnosed with cancer of the appendix which has spread within the abdomen. You have been told that you need surgery and that HIPEC will be a part of the operation. Many small tumors may be spread throughout the abdomen and on the surface of organs in the abdomen. They produce a mucous-like substance that is usually referred to as “mucin”. HIPEC was developed to help treat this condition.
The HIPEC procedure is usually done towards the end of the operation and involves circulating a chemotheraputic agent dissolved in a solution into the patient’s abdomen through the incision site. HIPEC has been proven to be more effective than standard chemotherapy that is administered by infusion through a vein. Higher levels of chemotheraputic agents can be established via HIPEC than conventional chemotherapy. This is possible since the lining of the abdomen, the peritoneum, is a large absorptive surface.
HIPEC consists of placing perfusion catheters into the abdomen (the peritoneal cavity), which are very similar to those used in heart surgery. There is an inflow catheter and an outflow catheter. Heated or hyperthermic chemotherapy, (the H in HIPEC) is pumped into the abdomen through the inflow catheter and exits through the outflow catheter. The operating table is then vibrated so that the fluid can circulate throughout the abdomen. The chemotheraputic agent (the C in HIPEC) is dissolved in the fluid. The fluid is directed into the peritoneal cavity (the PE in HIPEC). The fluid is heated to 107 degrees Fahrenheit to achieve greater penetration of the chemotheraputic agent. This part of the operative procedure may take about one and a half hours.
HIPEC is usually done along with CRS, which stands for “cyto-reductive surgery”. After the patient is anesthetized, this part of the operation proceeds first and consists of removal of the sites of the tumor and mucin and may involve removal of some internal solid organs, such as the gall bladder, spleen, and part of the intestine.
After the CRS is completed, the perfusion tubes for HIPEC are placed into the patient’s abdomen and the incision is closed. Once the HIPEC perfusion is complete, the abdomen is re-opened to be certain that nothing is amiss and then the abdomen is closed. The length of the surgery is variable, depending on the amount of dissection done during the CRS. A patient’s recovery time in the hospital is variable. It depends in part on the amount of dissection done during the CRS. The more drastic the organ removal and the more intestinal work done, the longer the recovery period.
…..I hope this helps you to understand both HIPEC and CRS. In another article, I will discuss what you can expect when you go home and what you can do to hasten your recovery.
If you have questions for Arthur, visit his web page today to submit a question to him: https://pmppals.net/ask-arthur/
Please remember, although PMP Pals tries to offer hope, support and information about appendix cancer and pseudomyxoma peritonei, we’re not medical professionals and we’re not qualified to provide medical advice. Please consult with your HIPEC Specialist to develop a medical care plan.
PMP Pals is proud to share that Dr. Lowy and the Peritoneal Surface Malignancy Program Team at UCSD have recognized the PMP Pals Network for their work in supporting appendix cancer patients and their caregivers. In their Spring Newsletter, Dr. Lowy’s team explains how PMP Pals complements their comprehensive approach to fighting cancer. The Newsletter notes “The fight against cancer is a team approach, and we want to be able to provide the best options for each of our patients.” PMP Pals is glad to be recognized along with the Patient Ambassador Program, which also does a terrific job in offering hope and support to patients who choose the team at UCSD.
Take a look at the Newsletter and you’ll find great information about our upcoming PMP Pals Annual Conference being held on October 8th & 9th in Monterey, California. We want to thank Shirley Tejidor and Lori McIntosh for thinking of us, and we hope to see you in Monterey later this year!
By Dani C., Pseudomyxoma Peritonei Survivor
As a woman who has undergone HIPEC surgery for appendix cancer (AKA pseudomyxoma peritonei), I’ve faced the difficulty of getting my groove on and once again enjoying physical intimacy with my husband. It’s probably the most embarrassing issue that you need to deal with during your recovery process. You find you’re finally ready for full intimacy, but your lady parts – what’s left of them – aren’t cooperating. It’s enough to make you scream…and not in the good way!
HIPEC surgery for pseudomyxoma peritonei often includes the removal of the uterus and ovaries. Which leaves us ladies without the hormones we need for natural vaginal lubrication. Vaginal dryness sounds like a minor thing until you attempt to engage in intimacy with your partner. Ouch is putting it mildly. Lack of hormones also thins the walls of the vagina, making any friction across these thin, dry walls torture. Over-the-counter lubricants can make intercourse bearable. But, ladies, we deserve more than just “bearable.”
It is possible to have a great sex life after appendix cancer surgery. I’m four years out, and back to a completely normal sex life. So let’s look at what you can do to get things fired back up.
Ladies, don’t despair. Your love life will return after appendix cancer. With time, patience, understanding…and a little coconut oil.
Blood clots can be a dangerous post-surgical complication. Many of us have several risk factors for these conditions, including age, the mere presence of cancer, having abdominal surgery, and our immobility during long hospitalizations.
Deep Vein Thromboses (DVTs) are blood clots that originate in the legs. If a blood clot breaks free and travels to the lungs it’s called a pulmonary embolism (PE), and can be fatal. It is important to know the signs and symptoms of each of these conditions and to report them to medical personnel immediately.
Common symptoms of a DVT are swelling of one or both legs; pain or tenderness in the leg(s), sometimes only while walking or standing; redness, visible veins, or warmth in the skin of the affected leg; and leg fatigue. Do NOT rub the leg in order to ease leg pain! Report it and let the medical professionals deal with it.
Some symptoms of PE are sudden coughing, which may bring up blood; sharp chest pain; shortness of breath; rapid breathing; rapid heartbeat; nausea and severe lightheadedness.
If, after a few days, you continue to have trouble breathing while doing everyday tasks, be sure to report this symptom to your surgeon or to the charge nurse.
Should these symptoms arise after your discharge from the hospital, go directly to the ER where the proper tests can determine if a blood clot is present.
Don’t be afraid to be assertive! Blood clots can be life threatening.
PMP Pals serves as a source of information to patients about centers of expertise for treating PMP and appendix cancer. In this blog, we focus on Dr. Edward Levine, a surgeon who has treated this form of cancer for 20 years. Dr. Levine is Chief of Surgical Oncology of the Comprehensive Cancer Center at Wake Forest Baptist Medical Center, where approximately 100 surgeries with HIPEC are performed annually. We spoke to him in January about a range of topics.
First, we are interested in how you came to be involved in treating appendix cancer patients.
My first case was in 1996. I became interested in focusing on this cancer because I saw that patients coming back to our clinic for check-ups were experiencing improved outcomes from the newer protocols being used – cytoreductive surgery with HIPEC. The older forms of treatment and protocols had much shorter survival for these patients. It was so encouraged to see this improvement in outcome that I expanded my efforts for potential HIPEC patients.
What is your longest surgery for PMP/appendix cancer? Is that your most memorable case?
My longest HIPEC was 19 hours. The good news is that the average length of surgery is coming down – for us, it currently is 9 hours. And, more importantly, the complication rates are coming down. Now, nearly half the patients undergoing surgery with HIPEC do not need to spend any time in the intensive care unit.
There is no one particular case that stands out as most memorable for me. What stays with me is seeing the long-term survivors’ photos of their grandchildren, their travels, and their active hobbies like kayaking. This is what makes an impression on me – seeing my patients able to enjoy these kinds of moments.
Are you currently involved in any research trials?
Yes, at Wake Forest we have several on-going studies in different areas. First, we have performed the largest quality of life study worldwide to date for patients undergoing HIPEC. We are looking at more than 600 patients in this study. We will present this study at the March 2016 meeting of the Society of Surgical Oncology. We are following up that study with one looking at caregivers for HIPEC patients. Additionally, we have a long term study on patient outcomes, looking at response to surgery survival after HIPEC.
We also are studying what makes tumors tick – looking at the genomics and genetics of tumor development from a scientific standpoint. And finally, we have a first ever Phase II clinical trial looking at the chemotherapy agents used in HIPEC for appendiceal cancers. I am serving as the principal investigator; we are working with the University of Pittsburgh and the MD Anderson Cancer Centers on this study, which is in the follow up phase now. We expect to be able to compile the results by the end of the year.
To patients I would say that even though your type of tumors is rare (only about 3,000 new cases per year), don’t feel alone. There is active research taking place for this type of cancer. And, groups like PMP Pals provide an important source of support to patients and caregivers.
What advice do you have for patients who are approaching CRS and HIPEC treatment?
That’s a good question. First, I would say to take time to prepare yourself well before the surgery. Come to this treatment in the best possible shape. By that I mean not just physiologically and nutritionally, but also your mental state and spiritual state – all of these are important. The better the shape you are in, the better the outcome.
Then, around the time of your surgery, prepare for things that will improve your quality of life in those weeks. Get to know your surgeon, talk about what to expect, get to know the hospital you will be spending time in. Both the patients and caregivers need to know their surroundings and their surgeon in order to keep stress in check and to take care of themselves as well as possible while going through surgery.
After surgery, your recovery is like a marathon, not a sprint. Often it can take 3 to 6 months for full recovery, and the surgery can be life changing. Patients need to be prepared for this and plan for adequate time and support to recover.
Let’s talk about chemotherapy. We find there is a lot of confusion about when systemic chemo is recommended for PMP tumors. Can you clarify this for patients?
For appendiceal cancer tumors of the low grade kind, with no nodal metastases, there is no evidence of benefit from systemic chemo. For high grade tumors, based on the genetics involved, we do offer systemic chemo. For high grade tumors, we see response rates that are similar to response rates for chemo for treating colon cancer. These high grade tumors respond to the same drugs used for colon cancer – specifically, oxaliplatin-based chemo drug regimens (often referred to as FOLFOX) are the best first line systemic chemo treatment. By contrast, the genes in low grade tumors are very different from those in both colon cancer tumors and high grade appendiceal cancer tumors. The low grade tumors are slow growing, and we do not see the same kind of impact from systemic chemo.
Dr. Levine, thank you for sharing your time with PMP Pals. We appreciate all you do to treat your patients as well as to improve medical treatment of appendiceal cancer and PMP in general.
You’re welcome. Likewise, I appreciate the ongoing effort and expanding role of PMP Pals. I have been involved with PMP Pals for many years and am glad to see the organization still here to provide support. Finding support from a group like PMP Pals is so important to patients and caregivers.
Systemic chemotherapy is prescribed for some patients with PMP and related cancers, either before surgery to reduce the tumor load, after treatment to prevent recurrence, or to enhance quality of life.
There are a variety of drugs that can be prescribed; the oncologist will choose the most appropriate ones for the patient’s individual situation. While the different drugs have their own side effects, it’s important to realize that they don’t affect all patients equally. While one patient may experience a variety of side effects, others may have very few. It’s essential to keep the oncologist informed of side effects, especially if they are intense, so that appropriate medicines can be added to reduce them or modifications to the treatment regimen can be made.
A list of chemotherapy drugs and their common side effects is found at the bottom of this article.
PMP Pals has been working with patients taking chemotherapy for many years, and several patients have shared their tips for coping with side effects.
Nausea or decrease in appetite are among the most common side effects of chemotherapy, but not everyone experiences them. Don’t automatically assume that you will be badly bothered by nausea. You may not, or it may be mild. There are several drugs that will calm nausea. If what your doctor prescribes doesn’t provide relief, be sure to contact him/her so that a substitution can be made. Always keep your nausea medication with you and be sure to take it when the nausea begins. Drink plenty of fluids; hydration is important. Eating small meals or snacks of bland foods frequently throughout the day can be helpful as well. Being outside in the fresh air can be beneficial, because some patients have a heightened sense of smell during chemotherapy and certain odors can bring on nausea. Some patients find benefit from a heating pad on the stomach. Antacids may be helpful, but check with your oncologist and do not exceed the maximum dosage. Medications prescribed to treat nausea associated with chemotherapy include Dexamethasone (Decadron), Avitan (Lorazepam), Zofran (Ondansetron), Compazine (Prochlorperazine), and Emend. Gravol (Dimenhydrinate), a motion sickness tablet available over the counter, may also be useful. Always check over the counter medications with your oncologist.
Fatigue often occurs the first few days following chemotherapy sessions, but usually improves by the end of a week. Take naps or get plenty of rest these first few days. If you must continue to work your regular schedule, try to schedule your chemotherapy sessions late in the week, so you can rest over the weekend. Rest is your recuperative mechanism.
Neuropathy is tingling, numbness or pain in your fingers or toes. if you experience this, report it and its intensity to your oncologist. If it’s severe, the chemotherapy dose or schedule may be adjusted. Sometimes neuropathy is temporary and abates several months after finishing chemotherapy treatments. Some have found that IV or oral supplementation with minerals (calcium and magnesium) can minimize neuropathy. Alpha-Lipoic acid is another supplement that benefits some patients. Acupuncture can be helpful. Ask your oncologist about these treatments if you encounter neuropathy.
Hand and Foot Syndrome is heightened sensitivity, drying and cracking of the skin on hands and feet. If this is mild, Working Hands Cream may be sufficient. If not, the doctor may prescribe a cream containing urea. Many patients find that applying cream and then wearing socks on both the hands and feet to bed at night is helpful with these symptoms.
Some of the chemotherapy regimens result in sensitivity to cold, even to touching cold objects. Consider wearing a hat and gloves, especially if you go outside in cold weather.
If you receive an injection for low white blood counts due to chemotherapy, there is an oral over-the-counter antihistamine called Claritin that, if taken before the injection, can often prevent the flu-like side effects.
Nosebleeds can occur in patients taking Avastin. Sit up straight and apply pressure below the nose if this occurs. If this is a common or severe problem, the oncologist should be made aware of it.
Some patients produce a lot of mucous in the nose and mouth on some regimens. If you experience this, be sure to always have tissues available; in your car, home, pocket or purse.
Hair loss, while temporary, can be very distressing. There is a product called Cold Cap that can reduce or eliminate hair loss. The cap is only available to patients who use a chemotherapy clinic that has special freezers for storing them. Ordinary freezer temperatures are not cold enough to be effective. Information and a list of facilities that have the equipment can be found at http://www.rapunzelproject.org/coldcaps.aspx
In order to avoid those “scorcher days” in the hottest summer months, schedule your chemo for early in the mornings so that you can return home before the hottest parts of the day. It is especially important to drink plenty of fluids when the weather is hot. Hydration is essential. Wearing loose clothing and nibbling on popsicles, snow cones and ice chips can also help to “keep your cool”. Avoid going outdoors in the middle of the day, whenever possible. If there is hair loss, a loose headscarf can be cooler for women than wearing a wig when at home.
Many patients have stated that attitude is everything. Distraction for the first few days following chemotherapy treatments is very helpful. Watch movies, make plans for a vacation when you feel better, email friends and family, etc. Remind yourself in those dark hours that this is temporary and the chemotherapy is poisoning the cancer. Rest when you are fatigued, eat when you are hungry, and engage in enjoyable activities when you feel able.
Table of Chemotherapies for PMP
|Brand Name||Generic Name||For||Administration||Mechanism||Common Side Effects|
|Mutamycin||Mitomycin-C||PMP||HIPEC||DNA crosslinker effectively kills bacteria||nausea, vomiting, loss of appetite or weight, sores in mouth and throat, headache, fainting, blurred vision, hair loss, loss of strength and energy, rash|
|Adrucil||5-FU||colon cancer||intravenous||interrupts DNA replication||nausea, vomiting, diarrhea, mucositis, headache, myelosuppression, alopecia, photosensitivity, hand-foot syndrome, maculopapular eruption, itech, cardiotoxicity, persisitent hiccups, mood disorders|
|Xeloda||Capecitabine||colon cancer||pill||metabolizes to 5-FU and interrupts DNA replication||nausea, vomiting, diarrhea, mucositis, headache, myelosuppression, alopecia, photosensitivity, hand-foot syndrome, maculopapular eruption, itech, cardiotoxicity, persisitent hiccups, mood disorders|
|Leucovorin||Folinic acid||enhancing 5-FU toxicity||pill, intravenous||provides a source of reduced folinates which stabilizes 5-FU|
|Eloxatin||Oxaliplatin||colon cancer||intravenous||inhibits DNA synthesis causing cell death||peripheral neuropathy, fatigue, nausea, vomiting, diarrhea, neutropenia, ototoxicity, extravastion, Hypokalemia, persistent hiccups|
|Camptosar||Irinotecan||colon cancer||intravenous||inhibits DNA replication and transcription||diarrhea, immunosuppression|
|Avastin||Bevacizumab||colon cancer||intravenous||inhibits growth of new blood vessels||hypertension, heightenend risk of bleeding, bowel perforation|
|Erbitux||Cetuximab||colon cancer||intravenous||epidermal growth factor receptor inhibitor||rash, fevers, chills, rigors, urticaria, pruritis, hypotension, bronchospasm, dyspnea, wheezing, angioedema, dizziness, ahaphylaxis, cardiac arrest|
|Vectibix||Panitumumab||colon cancer||intravenous||epidermal growth factor receptor inhibitor||skin rash, fatigue, nausea, diarrhea, decreased magnesium levels|
|Removab||Catumaxomab||ascites||intraperitoneal||binds to EpCAM-positive tumors to enlist immune system response||fever, nausea, vomiting|
|Lonsurf||trifluridine + tipiracil||colon cancer||pill||incorporates into DNA during synthesis and inhibits tumor growth||anemia, neutropenia, fatigue, nausea, throbocytopenia, decreased appetite, diarrhea, vomiting, abdominal pain, pyrexia|
Contributors to this article include Elaine, Paul, Karen, Joanne, Mark, Robert, Andy, Warren, Sandra, Misty, and Gabriella Graham.
I’ve recently been asked what patients may have done to cause their appendix cancer to recur more aggressively. In this blog I’ll share some thoughts on why pseudomyxoma peritonei (PMP) may change over time and the strategies you might employ to combat these changes. It’s an important discussion because it’s natural for PMP to change and it’s not necessarily something we can control. Obviously, we want to do the best we can to manage the things in our control, but life is always a balancing act.
Cancer is by definition normal cells that have mutated genetically, often due to a combination of factors, some of which we control and some o
f which we do not. Those factors which are uncontrollable include the genetics we inherit from our parents and the pollution in our environment. Factors we can control include our diet, exercise and amount of rest we get. But it’s often a mixed bag of what we control and what we can’t, even for the things we’re able to manage.
Cancer patients struggle daily with the emotional challenges of worrying about their well-being and (potentially) the physical challenges stemming from the aggressive treatments enlisted in the hopes of curing them of PMP. It’s easy to imagine how this would have a direct impact on a patient’s stress level and amount of sleep they get. Perhaps more difficult to imagine is, although cancer patients want to eat a healthy diet of fruits and vegetables, it may be more difficult than usual due to nausea from chemotherapy or intestinal blockages following surgical procedures. In the balance of all things, what’s most important is that patients get enough calories to maintain their weight, take all medications as prescribed by their doctors and maximize the amount of fruits and vegetables they can tolerate.
Once PMP is established its tendency is to change and become resistant to treatments. Cancerous cells have inherently lost the natural ability that our healthy cells have: to monitor their health and to kill themselves if they become unhealthy (the normal ability of a cell to kill itself when unhealthy is called apoptosis). As cancer cells multiply over time, they also continue to mutate and change unchecked due to their faulty reparative systems. These continual changes can cause the cancer to stop responding to treatments it responded to before (cancer is called refractory when it stops responding to treatment that worked before). This is a normal part of how cancer works, unfortunately.
The standard of care for the treatment of appendix cancer and PMP is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC). The hope for CRS HIPEC is to remove all PMP in the body, all at once in one shot. If you have a higher grade tumor, chemotherapy may be added in case there’s any microscopic, persistent or residual disease not removed by CRS HIPEC (chemotherapy administered immediately following another treatment in the hopes of eradicating any remaining disease is called consolidation therapy).
Please understand that just because PMP becomes resistant to one treatment, doesn’t mean it can’t ultimately be controlled through another. We are aware of patients that have repeated CRS HIPEC and used a different chemotherapeutic agent during HIPEC, which has ultimately gotten rid of the disease (typically Mitomycin C is used, but we’re heard of other agents, like Melphalan, being successfully used in repeat surgeries). This is something you can discuss with your physicians as a possibility for you or the patient you’re caring for.
Most importantly, and sometimes most difficult to understand (and this is where things get philosophical), whether you’re fighting cancer or not, our encouragement is for you to make the most of every day you have. We know PMP patients and caregivers across the continuum of the journey of life, and no matter what your circumstances, you can do great things. It’s not always easy but you can manage life even with PMP. At the PMP Pals Network we’re more than happy to introduce you to other patients and caregivers that have navigated these waters. If you’re interested in learning more, send us an email at firstname.lastname@example.org or submit a request for a mentor at pmppals.net, and our team will get back to you right away. We have HOPE for YOU.
Chris Piekarski – President, PMP Pals. PMP Survivor since 2004.