Will I have pain?

One of the reasons people fear cancer so much is pain; they are afraid that if they have pain, they will have no way to relieve it. But having cancer does not necessarily mean that you will have pain. Some cancers cause no physical pain at all. Even people with advanced cancers do not always have pain; however, if pain does occur, there are many ways to relieve or reduce it. In addition to medicines, there are other ways to help manage pain such as imagery, biofeedback, relaxation, distraction, surgery, and nerve blocks. A combination of pain control methods can be used if needed.

Some people don’t want to take pain medicines because they are afraid they will become addicted. Research has shown pain medicines, if used properly, can be taken for as long as they are needed by people with cancer and they won’t become addicted. People with cancer do not take pain medication to get “high” -- they take pain medication to ease their pain. People also worry that if they take their medicines continuously, they will become "immune" to that dosage and need higher and higher doses until no dosage will work. In reality, increasing the dosage gradually as needed over time for most prescribed medicines increases their effectiveness.

Will I be able to work during treatment?

The answer to this question depends on the type of treatment you are getting, the stage of your cancer, how you feel, and the kind of work you do. Some people with cancer can go to work or enjoy leisure activities while they are being treated. Others find that they need more rest than usual and cannot do as much. Your doctor may suggest that you cut back on some of the things you do.

Many people can keep working while they are being treated. You may be able to schedule your treatments late in the day or right before the weekend, so that they interfere with your work as little as possible. If your treatment makes you very tired, you might want to think about adjusting your work schedule for a while. Tell your employer what you need and would like to do right now. You may be able to agree on a part-time schedule, or perhaps you can do some of your work at home. Under federal and state laws, some employers may have to let you work a flexible schedule to meet your treatment needs.

What side effects will I have from my treatment?

You are not alone if you have questions about side effects. Before treatment starts, most people are concerned about whether they will have side effects and, if so, what they will be like. Remember, every person doesn't get every side effect, and some people get few, if any. The severity of side effects also varies greatly from person to person.

Be sure to talk to your doctor and nurse about which side effects you are most likely to have with your treatment, how long they might last, how serious they might be, and when you should seek help for them. Your doctor may prescribe medicines to prevent some side effects before they appear. Although side effects can be unpleasant, it might help get through them if you weigh them against your treatment's ability to destroy cancer.

Most side effects will gradually go away after your treatment ends. The time it takes to get over some side effects and get your energy back varies from person to person and depends on many things, including your overall health and the treatment you are getting.

Although many side effects go away fairly quickly, some may take months or years to disappear completely. Sometimes the side effects can last a lifetime, such as when treatment causes permanent damage to the heart, lungs, kidneys, or reproductive organs. Certain types of treatment occasionally cause delayed effects, such as a second cancer, that may show up many years later.

Patients often become discouraged about how long their treatment lasts or the side effects they have. If you feel you are becoming discouraged, talk to your doctor. You may be able to change your medicine or treatment schedule. Also, your health care team should be able to suggest ways to reduce your pain and discomfort.

Some common side effects of colorectal cancer treatment include:

Fatigue

Fatigue is the feeling of being tired physically, mentally, and emotionally. It means having less energy to do the things you normally do or want to do. Cancer-related fatigue is defined as an unusual and constant sense of tiredness that can occur with cancer or cancer treatment. It is chronic when it lasts over time and interferes with usual activities. This fatigue is different from the fatigue of everyday life, which is usually temporary and relieved by rest. This fatigue is more severe and distressing. Rest does not always relieve it. For some people, this kind of fatigue can be more distressing than pain, nausea and vomiting, or depression. Cancer-related fatigue can:

• vary in its unpleasantness, severity, and amount of time that it is present 
• be overwhelming and hinder your ability to feel well 
• make even being with your friends and family difficult 
• decrease your ability to continue normal activities, including going to work 
• make it hard to follow your cancer treatment plan

Many patients with cancer say fatigue is the most distressing symptom of their cancer and its treatment. It is one that drastically affects the quality of their life. However, they rarely describe their symptom as 'fatigue' unless their health care team suggests it. Only you know if you have fatigue and how severe it is. No lab tests or x-rays can diagnose or determine the level of fatigue. The best measure of fatigue comes from your own report to the health care team.

You can describe your level of fatigue as none, mild, moderate, or severe, or you can use a scale of 0 to 10, where a 0 means no fatigue, and a 10 means the worst fatigue you can imagine.

During cancer treatment, you may find that you become tired more easily because your body uses more energy to handle the demands of cancer and treatment. Stress related to your illness, daily trips for treatment, and the effects of radiation on normal cells may also add to fatigue. Most people begin to feel tired after a few weeks of treatment. Fatigue usually gets worse as your treatment goes on.

Symptoms of fatigue are often caused by more than one problem, and although treating a specific problem, such as anemia (a low red blood cell count), may make you feel better, you may still need to do other things. That is why treatment for cancer-related fatigue has many different approaches that may or may not include medicines. Because of this, treatment may involve many health professionals, including doctors, nurses, social workers, physical therapists, nutritionists, and a number of others. Education and counseling are part of the treatment and help people learn how to conserve energy, reduce stress, and use distraction to think about things other than fatigue.

If the cause of fatigue is known, treatment will be directed to the cause. For example, if anemia is adding to the symptoms of fatigue, the anemia will be treated. In another patient, treatment may include correcting fluid and mineral imbalances. Exercise, treatment of sleep problems, and correcting nutrition problems all seem to improve fatigue. Exercise seems to have the greatest effect.

If you understand fatigue, you can cope with it better and reduce your distress. A family member may be able to help you talk to your health care team about your fatigue. The best approach is to learn about fatigue before you have it.

This weakness or weariness will go away gradually after your treatment is finished. Until then there are some things that you can do to help reduce fatigue.

Ways to reduce fatigue:

• List your activities according to how important they are to you when you have the most energy. 
• Ask for help and give other people tasks when you can. 
• Put things that you use often close by to save energy. 
• Establish a daily routine. 
• Reduce stress using methods such as deep breathing, visual imagery, meditation, prayer, talking with others, reading, listening to music, painting, or any other activity that gives you pleasure. 
• Keep a journal. 
• Balance rest and activities. Avoid too much bed rest, which can promote weakness. Schedule activities so that you have time for plenty of rest that does not interfere with nighttime sleep. Shorter rest periods are reported to be better than one long one. 
• Talk to your doctor about how to keep your pain, nausea, and depression under control. 
• Discuss physical exercise with your doctor before you start an exercise program. Get fresh air if possible. 
• Unless you are given other instructions, eat a balanced diet that includes protein (meat, milk, eggs, and beans), and drink about 8 to 10 glasses of water a day.

Let your doctor or nurse know about your fatigue and talk with them if:

• Your fatigue does not get better, keeps coming back, or becomes severe. 
• You are feeling tired and it is not related to something you are doing. 
• Your fatigue doesn’t get better when you rest or sleep. 
• You become confused or cannot concentrate. 
• You are unable to get out of bed for more than 24 hours. 
• Your fatigue disrupts your social life or daily routine.

Nausea and vomiting

Nausea and vomiting are 2 of the most common and most dreaded side effects of cancer treatment. How often you feel these side effects and how severe they may be depends on the treatments you are receiving and how they affect you.

Nausea and vomiting usually start a few hours after treatment and last a short time. Sometimes, but less often, severe nausea and vomiting can last for a few days. Be sure to tell your doctor or nurse if you are very nauseated, have been vomiting for more than a day, or if your nausea is so bad that you cannot keep liquids down.

The good news is that both symptoms can almost always be lessened by a change in the way you eat and with drugs called anti-emetics (or anti-nausea medicines) that help relieve nausea and vomiting. Many different anti-emetics are available today for treating and preventing nausea and vomiting. Different anti-emetics work for different people. You might have to try more than one before you get relief. Don't give up. Keep working with your doctor and nurse to find the one that works best for you. If your doctor has not prescribed an anti-emetic for you, please ask about one.

Many people feel queasy even before a treatment session begins. This is called anticipatory nausea, and it is very real. The best way to handle anticipatory nausea is through effective anti-emetics to prevent vomiting and with relaxation techniques.

Ways to help with nausea and vomiting:

• Avoid big meals so your stomach won't feel too full. Eat frequent small meals throughout the day instead of one, two, or three large meals. 
• Drink liquids at least an hour before or after mealtime instead of with your meals. 
• Eat and drink slowly. 
• Stay away from sweet, fried, or fatty foods. 
• Eat foods cold or at room temperature so you won't be bothered by strong smells. 
• Chew your food well so you can digest it more easily. 
• If you are nauseated in the morning, try eating dry foods such as cereal, toast, or crackers before getting up. (Don't try this if you have mouth or throat sores or are troubled by a dry mouth.) 
• Drink cool, clear liquids such as apple juice, tea, or ginger ale that has lost its fizz. 
• Suck on ice cubes, mints, or tart candies. (Don't eat tart candies if you have mouth or throat sores.) 
• Try to avoid odors that bother you, such as cooking smells, smoke, or perfume. 
• Rest sitting up in a chair after eating, but don't lie flat for at least two hours after you've finished your meal. 
• Wear loose-fitting clothes. 
• Breathe deeply and slowly when you feel nauseated. 
• Distract yourself by chatting with friends or family members, listening to music, or watching a movie or TV show. 
• Use relaxation techniques. 
• Avoid eating for at least a few hours before treatment if nausea usually occurs.

Low blood cell counts

Your bone marrow produces 3 important blood components:

• red blood cells, which carry oxygen to cells throughout the body 
• white blood cells, which fight infection 
• platelets, which help blood clot and stop bleeding

Chemotherapy treatments destroy some of the bone marrow cells so fewer blood cells are produced. A drop in the levels of any of these cells results in specific side effects. Your doctor will check your blood cell count often during your treatment and may give you growth factors to help your bone marrow make new blood cells.

Anemia: When you have too few red blood cells, your body tissues don't get enough oxygen to do their work. This condition is called anemia. You may have these symptoms: fatigue, dizziness, paleness, a tendency to feel cold, or shortness of breath.

Try the suggestions listed to combat fatigue to fight those caused by anemia. Report any symptoms to your doctor or nurse. If your doctor finds that your red blood cell count has fallen too low, you may need a blood transfusion or treatment with a drug to boost red blood cell production by the bone marrow.

Infection: Having low white blood cell counts decreases your ability to fight infections. Infections can begin in almost any part of your body, and most often start in your mouth, skin, lungs, urinary tract, rectum, and reproductive organs. One type of white blood cell, neutrophils, is especially important in fighting infections. A shortage of neutrophils is called neutropenia.

If your white blood cell count drops too much, your doctor may postpone treatment, give you a lower dose of chemotherapy, or prescribe treatment with a medicine that boosts white blood cell production in the bone marrow.

Ways to help prevent infections:

• Wash your hands often during the day, especially before you eat and before and after you use the bathroom. 
• Stay away from people who have diseases you can catch, such as a cold, the flu, measles, or chickenpox. 
• Avoid crowds when possible. 
• Do not get any immunization shots without checking first with your doctor to see if it's all right. 
• Stay away from people who recently have been vaccinated for chicken pox, smallpox, or the flu. (Check with your doctor about which vaccines are important and for how long after you should stay away.) 
• Clean your rectal area gently but thoroughly after each bowel movement. Ask your doctor or nurse for advice if the area becomes irritated or if you have hemorrhoids. Also, check with your doctor before using enemas or suppositories. 
• Don't cut or tear the cuticles of your nails. 
• Be careful not to cut or nick yourself when using scissors, needles, or knives. 
• Use an electric shaver instead of a razor to prevent breaks or cuts in your skin. 
• Use an extra soft toothbrush that won't hurt your gums. 
• Don't squeeze or scratch pimples. 
• Take a warm (not hot) bath, shower, or sponge bath every day. Pat your skin dry using a light touch. Don't rub. 
• Use lotion or oil to soften and heal your skin if it becomes dry and cracked. 
• Clean cuts and scrapes right away with warm water, soap, and an antiseptic. 
• Wear protective gloves when gardening or cleaning up after animals and others, especially small children.

Even if you are being extra careful, your body may not be able to fight off infections when your white blood cell count is low. Be alert to the signs and symptoms of an infection and check your body regularly for signs, paying special attention to your eyes, nose, mouth, and genital and rectal areas.

Symptoms of infection:

• fever of 100.5° F or greater 
• chills 
• sweating 
• loose bowels (This also can be a side effect of chemotherapy.) 
• a burning feeling when you urinate 
• a severe cough or sore throat 
• unusual vaginal discharge or itching 
• redness, swelling, or tenderness, especially around a wound, sore, pimple, IV catheter site, or vascular access device such as a port or special IV line 
• abdominal pain

Report any signs of infection to your doctor right away. If you have a fever, don't use aspirin, acetaminophen, or any other medicine to bring down your temperature without first checking with your doctor.

Bleeding or clotting problems: Chemotherapy drugs can affect your bone marrow's ability to make platelets. These are the blood cells that help stop bleeding by plugging up damaged blood vessels and by helping your blood to clot. If your blood does not have enough platelets, you may bleed or bruise more easily than usual, even from a minor injury.

Signs to report to your doctor:

• unexpected bruising 
• small red spots under the skin 
• reddish or pinkish urine 
• black or bloody bowel movements 
• any bleeding from your gums or nose
• bad headaches 
• dizziness 
• an increase in weakness 
• pain in joints and muscles

Your doctor will check your platelet count often during your treatment. If it falls too low, you may need a platelet transfusion.

Ways to avoid problems if your platelet count is low:

• Don't take any medicine without first checking with your doctor or nurse. This includes aspirin-free pain relievers, such as acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve), and any other medicines you can buy without a prescription. Some of these medicines can weaken the platelets and make bleeding problems worse. 
• Don't drink any alcohol unless your doctor says it's all right. 
• Use an extra soft toothbrush to clean your teeth. 
• Clean your nose by blowing gently into a soft tissue. 
• Take care not to cut or nick yourself when using scissors, needles, knives, or tools. 
• Be careful not to burn yourself when ironing or cooking. Use a padded glove when you reach into the oven. 
• Avoid contact sports and doing other things that might cause an injury. 
• Use an electric shaver instead of a razor.

Hair loss

Hair loss (alopecia) can be devastating. Not all chemotherapy drugs will make you lose your hair, and some people only have mild thinning that no one else notices. Your doctor or nurse will be able to tell you if your medicine is likely to make you lose your hair.

Hair loss can occur on all parts of the body, not just the head. Facial hair, arm and leg hair, underarm hair, and pubic hair all may be affected. And it usually doesn't happen right away. More often, hair loss begins after a few treatments. At that point, hair may fall out gradually or in clumps. Any hair that remains may become dull and dry.

Radiation therapy also can cause hair loss, but only in the area being treated. For example, if you receive radiation to your hip, you will not lose hair from your head. However, radiation to your head may cause you to lose some or all of the hair on your scalp.

Most patients find that their hair grows back after the treatments are finished, but it might be a different color or texture. Accepting hair loss can be difficult.

Ways to help with hair loss:

• Use mild shampoos. 
• Use soft hairbrushes. 
• Use low heat if you must use a dryer. 
• Don't use brush rollers to set your hair. 
• Don't dye your hair or get a permanent. 
• Have your hair cut short. A shorter style will make your hair look thicker and fuller. It also will make hair loss easier to manage if it occurs. 
• Use a sunscreen, sun block, hat, scarf, or wig to protect your scalp from the sun. 
• Use a satin pillowcase.

Sometimes, either during the re-growth of your hair or when you are bald, your scalp may feel dry and itchy. Keeping your scalp clean by using a moisturizing shampoo and conditioner may help. Use gentle creams or lotions on your scalp as needed. Even a gentle scalp massage may make your scalp feel more comfortable.

After chemotherapy your hair may have changes in its texture and fullness. Hair dyes contain chemicals like peroxide that can damage hair. Although there is nothing that has shown that hair dye damages hair more after chemotherapy, most doctors recommend patients not use hair dyes until the hair returns to normal. This may be as long as up to 6 months after treatment.

Some people who lose all or most of their hair choose to wear turbans, scarves, caps, wigs, or hairpieces. Others leave their heads uncovered. Still others switch back and forth, depending on whether they are in public or at home with family and friends.

If you choose to cover your head with a wig or hairpiece:

• Shop for your wig or hairpiece before you lose a lot of hair so you can match your natural color, texture, and style. Remember though that your head size will be smaller once you lose your hair. 
• You may be able to buy a wig or hairpiece at a specialty shop just for cancer patients. Also, a sales associate may be able to come to your home to help you. 
• You also can buy a wig or hairpiece through the American Cancer Society's tlc catalog. To request a copy of tlc, call 1-800-850-9445, or browse the catalog online at http://www.tlcdirect.org.
• If you would prefer to borrow rather than buy a wig or hairpiece, call your local American Cancer Society or check with the social work department at your hospital. 
• If you need a hairpiece because of cancer treatment, it is a tax-deductible expense and may be at least partially covered by your health insurance. Be sure to check your policy, and ask your doctor to write a prescription for a "hair prosthesis."

Diarrhea

Diarrhea is a common side effect of some chemotherapy drugs used for colorectal cancer. In some cases, the doctor may prescribe medicine for it to be taken before or during treatment, but don't take any over-the-counter medicines for diarrhea without asking your doctor first. If you have diarrhea that continues for more than 24 hours, or if you have pain and cramping along with it, call your doctor.

Ways to help control diarrhea:

• Eat smaller amounts of food, but eat more often. 
• Avoid high-fiber foods, which can cause diarrhea and cramping. High-fiber foods include whole grain breads and cereals, raw vegetables, beans, nuts, seeds, popcorn, and fresh and dried fruit. Eat low-fiber foods instead, such as white bread, white rice, or noodles, creamed cereals, ripe bananas, canned or cooked fruit without skins, cottage cheese, yogurt, eggs, mashed or baked potatoes without the skin, pureed vegetables, chicken or turkey without the skin, and fish. 
• Avoid coffee, tea, alcohol, and sweets. 
• Stay away from fried, greasy, or spicy foods. 
• Avoid milk and milk products if they make your diarrhea worse. 
• Eat more potassium-rich foods such as bananas, oranges, potatoes, and peach and apricot nectars, unless your doctor has told you otherwise. 
• Drink plenty of fluids to replace those you have lost through diarrhea. Mild, clear liquids, such as apple juice, water, sports drinks, weak tea, clear broth, or ginger ale are best.

If your diarrhea is severe (meaning that you have had seven or eight loose stools in 24 hours), tell your doctor right away. Ask if you should try a clear liquid diet to give your bowels time to rest.

As you feel better, gradually add low-fiber foods. A clear liquid diet doesn't have all the nutrients you need, so don't follow one for more than 3 or 4 days. If your diarrhea doesn't improve, you may need to have fluids given to you through a vein (IV fluids) to replace the water and nutrients you have lost.

Constipation

Some people become constipated during treatment. Others may become constipated because they are less active or are eating less than usual, or because they are taking certain pain medicines.

Tell your doctor if you have not had a bowel movement in 2 or more days. You may need to take a laxative or stool softener or use an enema, but don't use these remedies unless you have checked with your doctor, especially if your white blood cell count or platelet count is low.

Ways to help with constipation include:

• Drink plenty of fluids to help loosen your bowels. Warm and hot fluids work especially well. 
• Eat a lot of high-fiber foods. High-fiber foods include bran, whole-wheat breads and cereals, raw or cooked vegetables, fresh and dried fruit, nuts, and popcorn. 
• Get some exercise. A regular exercise program or simply going out for a walk can help. Be sure to check with your doctor before increasing physical activity.

Skin problems

You may have skin reactions to chemotherapy, including redness, itching, peeling, and dryness, especially if you are receiving 5-fluorouracil (5-FU) or capecitabine (Xeloda). Of the skin reactions to these drugs, the most severe is a blistering rash, most common on the palms of the hands or soles of the feet. The rash is painful, and may cause tingling as well.

This symptom seems to be related to higher doses of the drug, or slow processing of the drug (caused by kidney or liver problems). This severe reaction usually occurs early in the course of therapy, and may limit how much of the drug you will be able to take.

Less severe skin reactions can include an overall pink and itchy rash or swelling from higher doses or longer times on treatment. It is also possible to develop darker skin, especially along the veins where chemotherapy medicines have been infused.

The drugs cetuximab (Erbitux) and panitumumab (Vectibix) can cause acne-like skin rashes on your face, neck, and torso.

If these skin reactions become severe, you may need to stop taking the medicine and treat the symptoms until the skin problem is gone. Skin symptoms can happen anytime during treatment, but usually get a lot better 5 to 7 days after stopping the medicine.

Ways to help relieve your discomfort and lessen further skin irritation:

• Use only lukewarm water and mild soap when washing. 
• Do not wear tight clothing over the irritated area. 
• Try not to rub, scrub, or scratch any sensitive spots. 
• Avoid putting anything that is hot or cold, such as heating pads or ice packs, on your skin, unless advised by your doctor. 
• Do not use powders, creams, perfumes, deodorants, body oils, ointments, lotions, or home remedies unless approved by your doctor or nurse. Many skin products can cause additional irritation. 
• If you expect to be in the sun for more than a few minutes, wear protective clothing (such as a hat with a broad brim and shirt with long sleeves) and use a sunscreen. Ask your doctor or nurse about using sunscreen lotions.

Some patients may also have changes in their nails such as bluish or darker coloring, lines across them or may even lose them. These changes are not usually painful, but can cause you to feel self-conscious. Since there is not specific treatment for these nail changes, you may want to cover your nails with polish.

Bladder irritation

Some treatments can irritate your bladder or cause temporary or permanent kidney damage. They may cause pain during urination, or your urine may change color (orange, red, or yellow) or to take on a strong or medicine-like odor. For a short time, the color and odor of semen may be affected as well.

Ask your doctor if your chemotherapy drugs are among those that have these effects, and tell your doctor if you have any symptoms that might mean a problem.

Watch for these signs of bladder irritation:

• pain or burning when you urinate 
• frequent urination 
• a feeling that you must urinate right away 
• reddish or bloody urine (Some chemotherapy will change the color of your urine; tell your doctor or nurse if this occurs.) 
• fever 
• chills

Drink plenty of fluids to ensure good urine flow and help prevent problems. Water, juice, coffee, tea, soup, soft drinks, broth, ice cream, popsicles, and gelatin are all considered fluids.

Loss of appetite

Side effects can include eating and digestion problems. You may completely lose interest in food during your treatment. Even if you are not hungry, it is important to keep your protein and calorie intake high. Doctors have found that patients who eat well can better handle their cancer and side effects.

Coping with short-term diet problems may be easier than you expect. There are a number of guides and recipe booklets for patients who need help with eating problems. For information about nutrition during cancer treatment, see Nutrition for the Person with Cancer.

There may be days when you just can't eat because of nausea or mouth and throat problems. You also can lose your appetite if you feel depressed or tired. If you have trouble swallowing, tell your doctor or nurse. If it is painful when you chew and swallow, your doctor may suggest a liquid diet. Many liquid nutrition drinks are available and come in a variety of flavors. You can get them at grocery and drugstores without a prescription or you can make them yourself. They can be combined with other foods or added to milkshakes.

Ways to perk up your appetite when it is poor and to make the most of it when you do feel like eating:

• Eat small meals or snacks whenever you are hungry. You don't have to eat 3 regular meals each day. 
• Vary your diet and try new foods and recipes. 
• Take a walk before meals, when possible. This may make you feel hungrier. 
• Change your mealtime routine. For example, eat by candlelight or in a different location. 
• Eat with friends or family members. When eating alone, listen to the radio or watch TV. 
• If you drink alcohol, ask your doctor if you should avoid alcohol during your treatment. Also, ask if it will interact with any medicines you are taking. 
• When you feel up to it, make some simple meals in batches and freeze them to use later. 
• Keep healthful snacks close by for nibbling when you get the urge. 
• If other people offer to cook for you, let them. Do not be shy about telling them what you would like to eat. 
• If you live alone, you might want to arrange for Meals on Wheels to bring food to you. Ask your doctor, nurse, or local American Cancer Society office about Meals on Wheels.

If you are able to eat only small amounts of food, you can increase the calories per serving by trying the following:

• Add butter or margarine. 
• Mix canned cream soups with milk or half-and-half rather than water. 
• Drink milkshakes or prepared liquid supplements between meals. 
• Add cream sauce or melted cheese to your favorite vegetables.

Some people find they can handle large amounts of liquids even when they do not feel like eating solid foods. If this is the case for you, try to get the most from each glassful by making drinks enriched with powdered milk, yogurt, honey, or prepared liquid nutrition drinks.

Sleep problems

Sleep problems can be defined as a change in usual sleeping habits. People who are being treated for cancer may tire more easily and may need to sleep more than usual. Sometimes the opposite problem occurs, and people may have trouble sleeping. Reasons for changes in usual sleeping habits include pain (see section on pain), anxiety, worry, depression (see section on depression), night sweats, or side effects of therapy. It is important to know the difference.

Ways to improve sleep habits:

• Sleep as much as your body tells you to, but while you are awake, try to exercise as least once a day. 
• Drink warm, caffeine-free drinks, such as warm milk with honey, before sleep. 
• Don’t drink coffee, tea, or colas late in the day. 
• Make sure you have a quiet setting for rest during the same period of time each day. 
• Take sleeping medicine or pain relievers prescribed by your doctor at a regular time each night. 
• Don’t take any sleeping medicine other than what was prescribed by your doctor. 
• Don’t “hold off” on sleep medicine; rather, always take it at a regular time if you cannot sleep. 
• Have someone give you backrubs or massage your feet. 
• Keep sheets clean and neatly tucked in and as free from wrinkles as possible. 
• Don’t ignore pain if you have it.

Surgical adhesions

In 1 out of 3 surgeries for colorectal cancer, scar tissue will form where the bowel is reconnected. Sometimes, these tissues grow together in an abnormal way; these areas are called adhesions. Adhesions may develop as early as a few months after surgery, or many years later.

Adhesions can narrow the inside of the bowel, slowing the movement of contents through it. Adhesions can also obstruct or block the bowel.

Symptoms of possible bowel obstruction include severe, constant abdominal pain, vomiting with all food or drink, fever, and a swollen abdomen. Report these symptoms immediately. If your doctor cannot see you right away, you may need to go to an emergency room for tests to see if you have an obstruction. Partial bowel obstruction may be managed by medicines that help speed the bowel contents along the tract, but surgery is also a possible treatment. Some patients are temporarily admitted to the hospital so they can be watched and treated until they have surgery.

Mouth sores and throat problems

Good oral care is important during cancer treatment. Some drugs can cause sores in the mouth and throat and can make them dry and irritated or cause them to bleed. Mouth sores are not only painful, they can become infected by the many germs that live in your mouth. Infections can be hard to fight during treatment and can lead to serious problems. It's important to take every possible step to prevent them.

Ways to keep your mouth, gums, and throat healthy:

• If you have time, see your dentist before you start treatment to have your teeth cleaned and to take care of any cavities, abscesses, gum disease, or poorly fitting dentures. 
• Ask your dentist to show you the best ways to brush and floss your teeth during chemotherapy. 
• Ask about a daily fluoride rinse or gel to help prevent decay because chemotherapy can make you more likely to get cavities. 
• Brush your teeth and gums after every meal. Use an extra soft toothbrush and a gentle touch. Brushing too hard can damage soft mouth tissues. 
• Ask your dentist to suggest a special type of toothbrush, floss or dental ribbon, and toothpaste if your gums are very sensitive. 
• Rinse your toothbrush well after each use and store it in a dry place. 
• Avoid commercial mouthwashes because they often contain large amounts of irritating salt or alcohol. Instead, ask your doctor or nurse about a mild mouthwash or a mouthwash with antibiotics to help prevent mouth infections.

Ways to deal with mouth sores:

• Ask your doctor if there is anything you can put on the sores and if he or she can prescribe medicine to ease the pain. 
• Eat foods cold or at room temperature. Hot and warm foods can irritate a tender mouth and throat. 
• Choose soft, soothing foods, such as ice cream, milkshakes, baby food, soft fruits (bananas and applesauce), mashed potatoes, cooked cereals, soft-boiled or scrambled eggs, cottage cheese, macaroni and cheese, custards, puddings, and gelatin. You can also puree cooked foods in the blender to make them smoother and easier to eat. 
• Avoid irritating, acidic foods such as tomatoes, citrus fruit, and fruit juice (orange, grapefruit, and lemon); spicy or salty foods; and rough, coarse, or dry foods such as raw vegetables, granola, and toast. 
• Do not smoke, chew tobacco, or drink alcohol because tobacco and alcohol can further irritate mouth sores.
• Stay away from sugary snacks. 
• Ask your doctor or nurse to recommend a good mouthwash. The alcohol content in some mouthwashes has a drying effect on mouth tissues. 
• Rinse your mouth with warm salt water every 1 to 2 hours as needed. 
• Sip cool drinks often throughout the day. 
• Eat or chew sugar-free candy or gum to help keep your mouth moist.

Will I be able to exercise during treatment?

Your exercise routine during cancer treatment will depend on your physical condition and your general health before you were diagnosed. Your doctor will be able to tell you if you can exercise. Exercise, with adequate periods of rest built into your day, can be helpful for a number of reasons. It can boost your energy level, relieve stress, decrease anxiety and depression, and stimulate your appetite. You can make a choice to exercise alone or with a group of friends.

If you enjoyed regular exercise before your diagnosis, staying active while you are being treated for cancer may help you feel like some areas of your life are still "normal." If you have surgery as part of your cancer treatment, your doctor may recommend some kinds of movement to prevent complications and maintain range of motion in your joints and muscles. Your doctor can help you determine the best activities and schedule for you.

Will I need a special diet?

When you are healthy, eating enough food to get the nutrients you need is usually not a problem. In fact, most nutrition guidelines stress eating lots of fruits, vegetables, and whole-grain products; eating a moderate amount of low-fat meat and dairy foods; and cutting back on fat, sugar, alcohol, and salt. During cancer treatment, however, eating may be hard, especially if you have side effects or simply don't feel well. As a result, you may need to change your diet to build up strength and withstand the effects of your cancer and its treatment.

Nutrition suggestions for people with cancer often emphasize eating lots of high-calorie, high-protein foods such as milk, cheese, and cooked eggs. If you lose weight, you may also be told to include more sauces and gravies and more butter, margarine, or oil in your foods to boost calories. In addition, you may be encouraged to eat fewer high-fiber foods, because fiber can worsen problems such as diarrhea.

The following side effects can affect your ability to eat:

• loss of appetite (anorexia) 
• weight loss or gain 
• sore mouth or throat 
• dry mouth 
• dental and gum problems 
• changes in taste or smell 
• nausea 
• vomiting 
• diarrhea 
• constipation 
• fatigue 
• depression

You may or may not have any of these side effects. Many factors determine whether you will have any and how severe they will be. These factors include the type of cancer, the part of the body affected, the type and length of treatment, and the dose of treatment.

Most side effects can be controlled and most go away after treatment ends. Talk to your doctor or nurse about your chances of having side effects and what they might be like. For more information, please see the American Cancer Society document Nutrition for the Person With Cancer.

Preparing yourself for cancer treatment

Until you begin treatment, you won't know exactly what, if any, side effects you may have or how they feel. One way to prepare for them is to think of your treatment as a time to concentrate on yourself and on getting well. Here are some ways to get ready:

Take control

You can reduce your anxiety about treatment side effects by having a positive attitude, talking about your feelings, and becoming well-informed about your cancer and treatment. In addition, planning ways to cope with possible side effects can make you feel more in control and help you keep your appetite.

Many people have few or no side effects that keep them from eating. Even if you have side effects, they may be mild and most go away after cancer treatment ends. In addition, you may be able to control side effects with new drugs that are available.

What if I need a colostomy?

A colostomy is created when a part of the colon is removed or bypassed. The remaining part of the functioning colon is brought through the abdominal wall in an opening called a stoma. This changes the way your body normally gets rid of its bowel contents.

A colostomy can be temporary or permanent. When part of the colon has been removed and the remaining portion needs time to heal, a colostomy temporarily keeps stool from reaching this part of the colon and eliminates it through the stoma. A temporary colostomy is usually in place 2 to 3 months, though healing can take up to a year. Eventually the temporary colostomy is "reversed" (the 2 ends of the colon are reattached) and normal bowel movements are resumed.

When cancer is in the descending or sigmoid part of the colon or the rectum, the diseased portion must be totally removed or permanently bypassed. In this case, a permanent colostomy provides a lasting alternate exit for stool. Your doctor may recommend a permanent colostomy if you have other health problems that make it unwise to have more surgery.

If your surgeon determines you will need a temporary or permanent colostomy, an enterostomal therapist or wound and ostomy care nurse (WOCN) will join your health care team. He or she will teach you about your colostomy and will help you obtain and use supplies correctly and adapt your lifestyle to the colostomy.

There are times after surgery when you may feel discouraged. You may feel alone and isolated. Because the whole experience is so new to you, you may feel awkward, frustrated, and uncertain. You may feel uncomfortable dealing with your personal body functions, and you may worry about how others might react. You may yourself feel some initial revulsion emptying your pouch. These feelings and reactions are normal. You might cry, be hostile or angry, and react in ways that are unusual for you.

Talking to your partner, a trusted friend, or a member of the clergy can help. The members of your health care team and other people with ostomies may also help you work through these feelings. Many patients say that they worried about not being able to see themselves in the same way again, and whether they would be able to regain and maintain their normal lifestyle. There will certainly be some changes as you adjust to a colostomy, but many people can attest to the fact that most aspects of your life can proceed as before you had an ostomy.

In the first weeks and months after your surgery, you may be asked to follow a low-residue diet of foods that are bland and easy to digest. After healing is complete and the ostomy is functioning normally, most people with colostomies can return to a regular diet. Introduce foods back into your diet a little at a time and monitor the effect of each food on the function of your ostomy.

People with ostomies take part in most types of physical activities including running, skiing, and swimming. However, you may want to avoid contact sports (which could injure the stoma) and heavy weight lifting (which could result in a hernia at the stoma). Ask your doctor if you are unsure before starting any physical activities.

Don’t avoid road trips, camping, cruises, and air travel because of your colostomy. There is no reason you can’t travel, as long as you take a few extra precautions. For example, leave home fully prepared and take along enough supplies to last the entire trip plus some extras in case your return is delayed. If you are taking a plane flight, carry an extra pouching system and other supplies on the plane with you in case your checked luggage gets lost.

People with colostomies can do just about everything they did before their surgery -- dine out, wear stylish clothes, go to work, take a bath, play sports, and have sex. In some cases, you may have to take a few extra precautions, but an ostomy should not prevent you from leading an active, healthy, happy life.

Ways to manage your colostomy:

• If you feel self-conscious, and think everyone can see your pouch even though it is hidden by your clothing, keep these questions in mind: Did you know what a colostomy was, or where a stoma was located, or what it looked like, before you had surgery? 
• If you find your pouch filling with gas and bulging under your clothing, a quick trip to the restroom can take care of this problem. 
• To muffle noisy discharges of gas, put your hand discreetly over the stoma. 
• If you are worried about your pouch filling up right after eating at a social event, remember, people without colostomies often need to go to the restroom after eating and nobody will think it unusual if you do the same. 
• Check the pouch occasionally to see if it needs emptying before it gets too full and causes a leakage problem. Always empty the pouch prior to going out of the house and away from a convenient toilet. 
• To empty the pouch, sit on the toilet with the pouch between the legs. Hold the bottom of the pouch up and remove the clamp. Slowly unroll the tail of the pouch into the toilet. Clean the outside and inside of the pouch tail with toilet paper. Replace the clamp. 
• Keep enough supplies on hand to avoid emergencies.

Will cancer affect my sex life?

For men, cancer surgery may stop your erections or ability to reach orgasm. In other cases, your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be made worse by the surgery. If you are a woman, most colorectal surgeries should not cause any loss of sexual function. Abdominal adhesions (scar tissue) may sometimes cause pain or discomfort during intercourse.

Sexual feelings and attitudes vary greatly among people, even under normal circumstances. This is also true during illness. Some people notice little or no change in their sexual desire and energy level. Others find that their sexual interest declines because of the physical and emotional stresses of having cancer and getting treatment. These stresses may include worries about changes in appearance; anxiety about health, family, or finances; or side effects, including fatigue and hormonal changes. However, some people find that they feel even closer to their partners during this time and have an increased desire for sexual activity.

If your sexual desire and energy level change during treatment, keep in mind that this is normal and can happen for a number of reasons. If you have had surgery for cancer in the pelvic or abdominal areas, it may make sexual intercourse difficult or painful for a time. Some women experience vaginal dryness and some men experience erectile dysfunction (inability to have an erection) as a side effect of some treatments. If you are comfortable doing so, discuss these concerns with your cancer care team.

If you were comfortable with and enjoyed sex before starting therapy, chances are you will still find pleasure in physical intimacy during your treatment. You may find that intimacy takes on a new meaning and you relate differently. Hugging, touching, holding, and cuddling may become more important, while sexual intercourse may become less important.

The most important part of maintaining or resuming sexual activity with a partner is good communication. A partner's concerns or fears, a normal part of the sexual relationship, can also have an impact on your sexual experiences together. Some may worry that physical closeness will harm the person who has cancer. Others may fear that they might "catch" the cancer or be affected by the radiation or chemotherapy. Talking openly about these things can clear up many misunderstandings. It will also help you find out what different things you can do to make the sexual experience enjoyable.

A healthy sex life can be hard to maintain when there are so many physical and emotional factors involved. Get as much information from your doctor and other resources as possible so that you have a full understanding of what you can and cannot do before, during, and after treatment. For more information, read the following documents: Sexuality and Cancer: For the Man Who Has Cancer and His Partner and Sexuality and Cancer: For the Woman Who Has Cancer and Her Partner.

Fertility

After chemotherapy or radiation therapy, women may find that their menstrual periods become irregular or stop. This does not necessarily mean that they are unable to become pregnant, so birth control may still be needed during treatment. Of course, if the uterus is removed during surgery, pregnancy will not be possible.

In men, the treatments may reduce or damage sperm cells. In many cases, fertility is restored after treatment is complete. Some surgeries can cause men to have "dry" orgasms (without semen) by damaging the nerves that control ejaculation. Sometimes the surgery only causes retrograde ejaculation, which means the semen goes backward into the bladder. This difference is important if you want to father a child. Retrograde ejaculation is less serious because infertility specialists can recover sperm cells from the urine, which can be used to fertilize an egg. If sperm cells cannot be recovered from your semen or urine, specialists may be able to retrieve them directly from the testicles by minor surgery, and then use them for in vitro fertilization.

Whether or not you plan to have children, concerns about how treatment will impact your fertility are normal. Discuss your questions about fertility before beginning cancer treatment with your doctor; he or she will help you decide which treatment is best for you.

How will I pay for my treatment?

The cost of treatment varies with the type of treatment, how long it lasts, how often it is given, and whether you are treated at home, in a clinic, office, or in the hospital. Most health plans, including Medicare Part B, cover at least part of the cost of many treatments. In many states, Medicaid may help pay for certain treatments. Before you begin treatment, find out whether your insurance company or Medicare will pay for your care. Find out also what part of the expense, if any, you will be responsible for.

If you are in a low-income bracket or are unemployed, check to see if you qualify for state or local benefits such as Medicaid. If you are currently employed and are thinking about leaving your job, find out about conversion options through your current plan. (Conversion options may allow you to switch from your employer’s insurance plan to an individual plan with similar coverage.) Many group plans have a clause for conversion to individual plans, although premiums may be considerably higher. These individual plans usually must be applied for within 30 to 60 days of leaving your job.

If you are looking at insurance options, look closely at differences in coverage between plans. Ask about your choice of doctors, as well as how you are protected against cancellations and increases in premiums (what you pay for insurance). Find out what the plan really covers, especially if you have a catastrophic illness (generally defined as an illness that prevents you from working). What are the deductibles? (Remember that many health insurance plans have different deductible amounts for different services.) Better comprehensive coverage sometimes has higher deductibles.

Most managed care plans should pay for you to take part in a clinical trial if your doctor recommends the treatment and if the clinical trial is approved by a trustworthy agency. These plans typically supply case managers or other personnel to whom your doctor can make the case for the need for drugs not covered.

Health maintenance organizations (HMOs) commonly provide preventive care and routine doctor visits; however, access to state-of-the-art cancer care is sometimes difficult to obtain through these organizations.

Learning about your health insurance will help you prepare not only for the expense of treatment, but also for the process of talking or writing to the many people involved in running your health insurance plan. Patients who understand their insurance and know how to work with the insurance company are more likely to be successful in getting the coverage they need. Sometimes it is necessary to go outside the plan for the cancer care that is best for you. Knowing in advance exactly what your health insurance will cover can give you some peace of mind as you make treatment decisions.

If you have a dispute with your health plan, there are ways to help you solve it. Always keep records of all aspects of care and interaction with health plan staff and clinicians. Your doctor is your ally and advocate. If the health plan won’t pay for your care, it is your doctor who may go to the proper administrator within the health plan, such as a medical director, to give more information about your case.

If you are not already insured, you have several choices to look at in seeking coverage, such as an independent insurance broker who may be able to help you locate a reasonable benefit package. Find out if you can apply for group insurance through professional organizations (such as those for retired persons, teachers, social workers, or real estate professionals).

What resources are available to help me?

There are many places where you can get assistance. Your hospital is one of the first sources that can help you get the support you need. Hospital support services are an important part of your care. Support services that may be available include nursing services, social services, nutritional services, rehabilitation services, or spiritual services.

Some people worry that asking for emotional support is a sign of weakness, as if they are somehow expected to "be strong" and handle the situation on their own. However, solitude and strength are not the same thing. You don’t have to be alone to be strong. Emotional support is crucial at every stage of the cancer journey, and it can come from many places. Along with your family and friends, consider contacting sources of support such as health professionals, support groups, and your place of worship. Asking for support is one way you begin to manage your situation. Talking with family and friends can bring comfort and reassurance.

Cancer can be an awkward thing to talk about, and sometimes people worry that they will upset you by bringing up the topic or talking about your illness. You may need to take the first step. Individual or group counseling or support groups can help you cope with the stresses your illness brings in your everyday life. Many people with cancer find it easier to talk with people who are going through experiences like theirs. Support groups can also provide important practical information about your cancer and its treatment. Community agencies can sometimes relieve the demands cancer places on families and friends.

Most importantly, a person with cancer is never alone. There are people who care and who are ready to help. For more information about cancer, topics addressed in this document, or American Cancer Society programs and services, contact us at 1-800-ACS-2345.

Last Revised: 03/05/2008