Burkitt's lymphoma (or "Burkitt's tumor", Burkitt lymphoma or "malignant lymphoma, Burkitt's type") is a cancer of the lymphatic system (in particular, B lymphocytes). It is named after Denis Parsons Burkitt, a surgeon who first described the disease in 1956 while working in equatorial Africa.[1][2]

ClassificationCurrently Burkitt's lymphoma can be divided into three main clinical variants: the endemic, the sporadic and the immunodeficiency-associated variants.

The endemic variant occurs in equatorial Africa. It is the most common malignancy of children in this area. Children affected with the disease often also had chronic malaria, which is believed to have reduced resistance to Epstein-Barr virus (EBV), allowing it to take hold. The disease characteristically involves the jaw or other facial bone, distal ileum, cecum, ovaries, kidney or the breast.

The sporadic type of Burkitt lymphoma (also known as "non-African") is another form of non-Hodgkin lymphoma found outside of Africa. The tumor cells have a similar appearance to the cancer cells of classical African or endemic Burkitt lymphoma. Again it is believed that impaired immunity provides an opening for development of the Epstein-Barr virus. Non-Hodgkin lymphoma, which includes Burkitt's, accounts for 30-50% of childhood lymphoma. The jaw is less commonly involved, compared to the endemic variant. The ileo-cecal region is the common site of involvement.

Immunodeficiency-associated Burkitt lymphoma is usually associated with HIV infection[3] or occurs in the setting of post-transplant patients who are taking immunosuppressive drugs. Burkitt lymphoma can be one of the diseases associated with the initial manifestation of AIDS.

By morphology (i.e. microscopic appearance) or immunophenotype, it is almost impossible to differentiate these three clinical variants. Immunodeficiency-associated Burkitt lymphoma may demonstrate more plasmacytic appearance or more pleomorphism, but these features are not specific.

EpidemiologyOf all cancers involving the same class of blood cell, 2% of cases are Burkitt's lymphoma.[4]

Malignant B cell characteristicsNormal B cells possess rearranged immunoglobulin heavy and light chain genes and each isolated B-cell possesses a unique IgH gene rearrangement. Since Burkitt lymphoma and other B-cell lymphomas are a clonal proliferative process, all tumor cells from one patient are supposed to possess identical IgH genes. When the DNA of tumor cells is analyzed using electrophoresis, a clonal band can be demonstrated, since identical IgH genes will move to the

same position. On the contrary, when a normal or reactive lymph node is analyzed using the same technique, a smear rather than a distinct band will be seen. This technique is useful since sometimes benign reactive processes (e.g. infectious mononucleosis) and malignant lymphoma can be difficult to distinguish.

Microscopy

Burkitt's lymphoma, standard H&E stain.

The tumor consists of sheets of a monotonous (i.e. similar in size and morphology) population of medium size lymphoid cells with high proliferative activity and apoptotic activity. The "starry sky" appearance seen[5] under low power is due to scattered tingible body-laden macrophages (macrophages containing dead body of apoptotic tumor cells). The old descriptive term of "small non-cleaved cell" is misleading. The tumor cells are mostly medium in size (i.e. tumor nuclei size similar to that of histiocytes or endothelial cells). "Small non-cleaved cells" are compared to "large non-cleaved cells" of normal germinal center lymphocytes. Tumor cells possess small amount of basophilic cytoplasm. The cellular outline usually appears squared off.

ImmunohistochemistryThe tumor cells in Burkitt lymphoma generally strongly express markers of B cell differentiation (CD20, CD22, CD19) as well as CD10, and BCL6. The tumour cells are generally negative for BCL2 and TdT. The high mitotic activity of Burkitt lymphoma is confirmed by nearly 100% of the cells staining positive for Ki67.[6]

GeneticsAll types of Burkitt's lymphoma are characterized by disregulation of the c-myc gene by one of three chromosomal translocations.[7] This gene is found at 8q24.

The most common variant is t(8;14)(q24;q32), which accounts for approximately 85%[7] of cases. This involves c-myc and IGH@. A variant of this, a three-way translocation, t(8;14;18), has also been identified.[8]

A rare variant is at t(2;8)(p12;q24).[9] This involves IGK@ and c-myc.

Another rare variant is t(8;22)(q24;q11).[9] This involves IGL@ and c-myc.

Combined, the two less-common translocations, t(2;8)(p12;q24) and t(8;22)(q24;q11), account for the remaining 15% of cases not due to the t(8;14)(q24;q32) translocation.[7]

Gene TargetsScientists from the National Cancer Institute (NCI), part of the National Institutes of Health, have uncovered a number of molecular signatures in Burkitt lymphoma, including unique genetic alterations that promote cell survival, that are not found in other lymphomas. These findings provide the first genetic evidence that Burkitt lymphoma is a cancer fundamentally distinct from other types of lymphoma.[10] The identification of TCF3 and ID3 gene mutations in Burkitt led the researchers to identify a potent cell survival pathway that might be attacked therapeutically. [11]

TreatmentTreatment includes dose-adjusted EPOCH with Rituxan (rituximab).[12]

The effects of the chemotherapy, as with all cancers, depend on the time of diagnosis. With faster growing cancers, such as Burkitt's, the cancer actually responds faster than with slower growing cancers. This rapid response to chemotherapy can be hazardous to the patient, as a phenomenon called "tumor lysis syndrome" could occur. Close monitoring of the patient and adequate hydration is essential during the process.

Chemotherapy

cyclophosphamide doxorubicin

vincristine

methotrexate

cytarabine

ifosfamide

etoposide

rituximab [13]

Other treatments are immunotherapy, bone marrow transplants, stem cell transplant, surgery to remove the tumor, and radiotherapy.

Prognosis

Treatment with dose-adjusted EPOCH with Rituxan (rituximab) has shown an 8 year survival rate of 91% for low risk, 90% for low-intermediate risk, 67% for high-intermediate risk, and 31% for high risk cases with few of the side effects associated with Burkitt's lymphoma chemotherapy.[12]

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Burkitt lymphoma is a very fast growing form of non-Hodgkin's lymphoma.

CausesBurkitt lymphoma was first discovered in children in certain parts of Africa, but it also occurs in the United States.

The African type of Burkitt lymphoma is closely associated with the Epstein-Barr virus (EBV), the main cause of infectious mononucleosis. The North American form of Burkitt lymphoma is not linked to EBV.

People with HIV have an increased risk for this condition. Burkitt lymphoma is most often seen in males.

SymptomsBurkitt lymphoma may first be noticed as a swelling of the lymph nodes (glands) in the neck, groin, or under the arm. These swollen lymph nodes are often painless, but can grow very rapidly.

In the types commonly seen in the United States, the cancer usually starts in the belly area (abdomen). The disease can also start in the ovaries, testes, brain, and spinal fluid.

Symptoms include:

Fever Night sweats

Unexplained swollen lymph nodes

Unexplained weight loss

Exams and Tests Bone marrow biopsy

Chest x-ray

CT scan of the chest, abdomen, and pelvis

Complete blood count (CBC)

Examination of the spinal fluid

Lymph node biopsy

PET scan

TreatmentChemotherapy is used to treat this type of cancer. Commonly used medicines include prednisone, cyclophosphamide, ifosfamide, vincristine, cytarabine, doxorubicin, methotrexate, and etoposide.

Outlook (Prognosis)More than half of those with Burkitt lymphoma can be cured with intensive chemotherapy. The cure rate may be lower if the cancer spreads to the bone marrow or spinal fluid. The outlook is poor if the cancer comes back after a remission.

Possible Complications Complications of treatment (radiation therapy or chemotherapy) Spread of the cancer

When to Contact a Medical ProfessionalCall your health care provider if you have symptoms of Burkitt lymphoma.

Alternative NamesB-cell lymphoma; High-grade B-cell lymphoma

Burkitt lymphoma is a form of non-Hodgkin's lymphoma in which cancer starts in immune cells called B-cells. Recognized as the fastest growing human tumor, Burkitt lymphoma is associated with impaired immunity and is rapidly fatal if left untreated. However, intensive chemotherapy can cure more than half of Burkitt lymphoma patients.

Burkitt lymphoma is named after British surgeon Denis Burkitt, who first identified this unusual disease in 1956 among children in Africa. In Africa, Burkitt lymphoma is common in young children who also have malaria and Epstein-Barr, the virus that causes infectious mononucleosis.

It's thought that malaria may weaken the immune system's response to Epstein-Barr, allowing it to change infected B-cells into cancerous cells. About 98% of African cases are associated with Epstein-Barr infection.

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Outside of Africa, Burkitt lymphoma is rare. In the U.S., about 1,200 people are diagnosed each year, and about 59% of patients are over age 40. Burkitt lymphoma is especially likely to develop in people infected with HIV, the virus that causes AIDS. Before highly active antiretroviral therapy (HAART) became a widespread treatment for HIV/AIDS, the incidence of Burkitt lymphoma was estimated to be 1,000 times higher in HIV-positive people than in the general population.

Types of Burkitt Lymphoma

In the World Health Organization classification, there are three types of Burkitt lymphoma:

Endemic (African). Endemic Burkitt lymphoma primarily affects African children ages 4 to 7, and is twice as common in boys as in girls.

Sporadic (non-African). Sporadic Burkitt lymphoma occurs worldwide. Globally, it accounts for 1% to 2% of adult lymphoma cases. In the U.S. and Western Europe, it accounts for up to 40% of pediatric lymphoma cases.

Immunodeficiency-associated. This variant of Burkitt lymphoma is most common in people with HIV/AIDS. It accounts for 30% to 40% of non-Hodgkin lymphoma in HIV patients, and may be an AIDS-defining disease. It also can occur in people with congenital conditions that cause immune deficiency and in organ-transplant patients who take immunosuppressive drugs.

Compared to the endemic variant, the incidence of Epstein-Barr infection is considerably lower in the sporadic variant (20%) and immunodeficiency-associated variant (30% to 40%). So the association of Epstein-Barr with these two types is unclear.

Symptoms of Burkitt Lymphoma

The symptoms of Burkitt lymphoma depend on the type. The endemic (African) variant usually starts as tumors of the jaw or other facial bones, although it also can affect the gastrointestinal tract, ovaries, and breasts. It also can spread to the central nervous system, causing nerve damage, weakness, and paralysis. 

The types more commonly seen in the U.S. -- sporadic and immunodeficiency-associated -- usually start in the bowel and form a bulky tumor mass in the abdomen, often with massive involvement of the liver, spleen, and bone marrow. These variants also can start in the ovaries, testes, or other organs, and spread to the brain and spinal fluid. 

Other symptoms associated with Burkitt lymphoma include:

Loss of appetite Weight loss

Fatigue

Night sweats

Unexplained fever

 

Diagnosis of Burkitt Lymphoma

Because Burkitt lymphoma spreads so quickly, prompt diagnosis is essential.

If Burkitt lymphoma is suspected, all or part of an enlarged lymph node or other suspicious disease site will be biopsied. In a biopsy, a sample of tissue is examined under a microscope. This will confirm or rule out Burkitt lymphoma. 

Additional tests may include:

Computed tomographic (CT) imaging of the chest, abdomen, and pelvis Chest X-ray

PET or gallium scan

Bone marrow biopsy

Exam of spinal fluid

Blood tests to measure kidney and liver function

Testing for HIV disease.

 

Treatments for Burkitt Lymphoma

Intensive intravenous chemotherapy -- which usually involves a hospital stay -- is the preferred treatment for Burkitt lymphoma. Because Burkitt lymphoma can spread to the fluid surrounding the brain and spinal cord, chemotherapy drugs also may be injected directly into the cerebrospinal fluid, a treatment known as intrathecal chemotherapy. 

Examples of drugs that may be used in various combinations for Burkitt lymphoma include:

cyclophosphamide (Cytoxan) cytarabine (Cytosar-U, Tarabine PFS)

doxorubicin (Adriamycin)

etoposide (Etopophos, Toposar, VePesid)

methotrexate (Rheumatrex)

vincristine (Oncovin)

Other treatments for Burkitt lymphoma may include intensive chemotherapy in combination with:

Rituximab (Rituxan), a monoclonal antibody that sticks to proteins on cancer cells and stimulates the immune system to attack cancer cells.

Autologous stem cell transplantation, in which the patient's stem cells are removed, stored, and returned to the body.

Radiation therapy.

Steroid therapy.

In some cases, surgery may be needed to remove parts of the intestine that are blocked, bleeding, or have ruptured.

Prognosis for Burkitt Lymphoma

Burkitt lymphoma is fatal if left untreated. In children, prompt intensive chemotherapy usually cures Burkitt lymphoma, leading to long-term survival rates of 60% to 90%. In adult patients, results are more variable. Overall, prompt treatment is associated with cure rates of 70% to 80%

What causes Burkitt's lymphoma?

The specific cause of non-Hodgkin lymphoma is unclear.  Some possibilities for factors that may increased your child’s risk of developing this cancer include:

genetics exposure to viral infections

Non-Hodgkin lymphoma has also been linked to chemotherapy and radiation therapy—it may be a second malignancy as a result of the treatment for certain cancers.

There has been much investigation into the association of non-Hodgkin lymphoma with:

the Epstein-Barr virus (EBV), which causes the infection mononucleosis (mono)

human immunodeficiency virus (HIV) , which causes acquired immune deficiency syndrome (AIDS)

Both of these infectious viruses have been linked to the development of Burkitt's lymphoma.

The majority of Burkitt's lymphoma cases result from a chromosome rearrangement between chromosome #8 and #14, which causes genes to change positions and function differently, promoting uncontrolled cell growth.

Other chromosome rearrangements have been seen in non-Hodgkin lymphoma (all types) are also thought to promote excessive cell growth. Children and adults with other hereditary abnormalities have an increased risk of developing non-Hodgkin lymphoma, including patients with:

ataxia telangiectasia X-linked lymphoproliferative disease

the Wiskott-Aldrich syndrome

What are the symptoms of non-Hodgkin lymphoma?

Most children have stage III or IV disease at the time of diagnosis because of the sudden onset of symptoms. The disease can progress quickly from a few days to a few weeks, and your child could go from otherwise healthy to having multi-system involvement in a short time period.

Some children with non-Hodgkin lymphoma have symptoms of an abdominal mass and complain of abdominal pain, fever, constipation and decreased appetite (due to the pressure and obstruction a large tumor in this area can cause). Some children with non-Hodgkin lymphoma have symptoms of a mass in their chest and complain of respiratory problems, dyspnea (pain with deep breaths), cough and/or wheezing.

Because of the rapid onset of this malignancy, any respiratory symptoms can quickly worsen, causing a life-threatening emergency.

While each child may experience symptoms differently, some of the most common include: 

painless swelling of the lymph nodes in neck, chest, abdomen, underarm or groin fever

sore throat

fullness in groin area from node involvement

bone and joint pain

night sweats

tiring easily

weight loss/decreased appetite

itching of the skin

recurring infections

The symptoms of non-Hodgkin lymphoma may resemble other blood disorders or medical problems. Always consult your child's physician for a diagnosis.

NURSiNG CARE PLAN

Nursing care plan assessment and physical examinationNote any history of infection with HIV, acquired immunodeficiency syndrome (AIDS), organ transplant, congenital immunodeficiency, autioimmune diseases, or other treatment with immunosuppressive drugs. Patients often have complaints of painless enlarged lymph nodes (commonly in the neck, mediastinum, or chest wall), fevers, night sweats, weight loss, weakness, and malaise. Because nodes and extranodal sites are more likely to be involved in NHL, the patient may also report vague abdominal distress (bleeding, bowel obstruction, cramping, ascites), symptoms of spinal cord compression, or back pain. Cough, dyspnea, and chest pain occur about 20% of the time and are indicative of lung involvement.

Carefully inspect all the locations for lymph nodes and the abdomen for signs of hepatosplenomegaly and ascites. Skin lesions that look like nodules or papules with a tendency to ulcerate appear in about 20% of cases. When palpating lymph node chains, examine the submental, infraclavicular, epitrochlear, iliac, femoral, and popliteal nodes. Involved nodes are characteristically painless, firm, and rubbery in consistency; they are in contrast to the rock-hard nodes of carcinoma because they are freely movable and of varying size. Palpate the liver or spleen, which may be enlarged. The patient may also have weight loss and fever.

The diagnosis of cancer is devastating at any time of life. Because the disease is most common in the older adult, the patient may be planning retirement. The diagnosis of NHL throws all retirement plans into disarray and may lead to feelings of loss, grief, and anger.

Nursing care plan primary nursing diagnosis: Risk for infection related to impaired primary and secondary defenses.

Nursing care plan intervention and treatment planTreatment is based on classification of the cell and staging of the disease. Some of the indolent types of NHL do well with only supportive therapy. The disease process may be slow enough that treatment is saved until the disease takes a more aggressive path. Most patients with intermediate- grade and high-grade lymphomas receive combination chemotherapy. Radiation is effective for many patients with stage I or II NHL. Radiation is delivered to the chest wall, mediastinum, axilla, and neck (the region known as the mantle field). Most patients, however, are at stage III or IV at diagnosis. Surgery has

limited use in the treatment of NHL. It may be part of the diagnostic and staging process, but diagnostic laparotomy is much less common than in Hodgkin’s disease. A therapeutic splenectomy may be performed for severe spleen enlargement. Gastric or bowel resection may be done if the patient has a primary gastrointestinal lymphoma or has obstructions from bulky nodes. Stem cell transplantation may be considered for patients who have relapsed, are at high risk for relapse, or have tried conventional therapy without success.

Maintain the patient’s comfort, protect the patient from infection, provide teaching and support about the complications of the treatment, and provide emotional support. Fatigue, one of the most common side effects of cancer treatment, can last for several months to several years. A program entitled “Fatigue Initiative Research and Education” (FIRE) is available through the Oncology Nurses Society (www.ons.org).

During irradiation, the patient may suffer from dry mouth, loss of taste, dysphagia, nausea, and vomiting, which can be managed with frequent mouth care. Explore ways to limit discomfort, such as ice chips. Attempt to provide desired foods to support the patient’s nutrition. Keep any foul-smelling odors clear of the patient’s environment, particularly during meals. Manage skin irritation and redness by washing the skin gently with mild soap, rinsing with warm water, and patting the skin dry. Encourage the patient to avoid applying lotions, perfumes, deodorants, and powder to the treatment area. Explain that the patient needs to protect the skin from sunlight and extreme cold. Before starting treatments, arrange for the patient to have a wig, scarf, or hat to cover any hair loss, which occurs primarily at the nape of the neck.

If the patient develops bone marrow suppression, institute infection controls. Treat the discomfort that may arise from chemotherapy—joint pain, fever, fluid retention, and a labile emotion state (euphoria or depression)—all of which need specific interventions, depending on their incidence and severity. The complexity of the diagnostic and staging process may make the patient feel lost in a crowd of specialists. It is important for the nurse to provide supportive continuity. Patience and repeated explanations are needed. Provide the patient with information about support groups, and refer the patient to a clinical nurse specialist, support groups associated with the American Cancer Society (www.cancer.org), or counselors.

Nursing care plan discharge and home health care guidelinesTeach the patient the following strategies to limit infections: avoid crowds, avoid infected visitors, particularly children with colds, wash the hands frequently; when an infection occurs, report it to a physician immediately; avoid direct contact with pets to limit the risk of infections from licks, scratches, or bites; do not change the cat litter or clean a birdcage. Maintain a high-calorie and high-protein diet. Take sips of grapefruit juice, orange juice, or ginger ale if nausea persists. Drink at least 2000 mL of fluid a day unless on fluid restriction. Perform frequent mouth care with a soft toothbrush and avoid commercial mouthwashes. Contact support groups, the American or Canadian Cancer Society, or counselors as needed.

http://www.enurse-careplan.com/2010/08/nursing-care-plan-ncp-non-hodgkins.html

Understanding Chemotherapy

What is chemotherapy?

Chemotherapy is a cancer treatment that uses drugs to destroy cancer cells. It is also called "chemo."

Today, there are many different kinds of chemotherapy. So the way you feel during treatment may be very different from someone else.

How can chemotherapy help me?

Chemotherapy can be used to:

Destroy cancer cells Stop cancer cells from spreading

Slow the growth of cancer cells

Chemotherapy can be given alone or with other treatments. It can help other treatments work better. For example, you may get chemotherapy before or after surgery or radiation therapy. Or you may get chemotherapy before a peripheral blood stem cell transplant.

How is chemotherapy given?

Chemotherapy can be given in these forms:

An IV (intravenously)

A shot (injection) into a muscle or other part of your body

A pill or a liquid that you swallow

A cream that is rubbed on your skin

When will I get chemotherapy?

You may get treatment every day, every week, or every month. The treatment period is followed by a period of rest when you won't get chemotherapy. This rest period gives your body a chance to build healthy new cells.

http://www.cancer.gov/cancertopics/coping/chemo-side-effects/understandingchemo

http://www.cancer.gov/cancertopics/coping/chemo-side-effects

Anemia

What is anemia?

Anemia is when your body doesn't have enough red blood cells. Having anemia can make you feel very tired or weak.

Try these tips when you feel tired or weak:

Save your energy.Choose the most important things to do each day.

Ask for help.When family or friends offer to help, let them. They can take you to the doctor, buy groceries, or make meals.

Balance rest with activity.

Take short naps during the day. Short naps of less than 1 hour are best. Too much bed rest can make you feel weak.

Sleep at least 8 hours every night.

You may feel better if you take short walks or exercise a little every day.

Eat and drink well.

Talk with your doctor or nurse to learn what foods and drinks are best for you.

You may need to eat high-protein foods. Meat, peanut butter, and eggs are good choices.

You may need to eat foods with iron. Red meat, leafy greens (such as collard greens and spinach), and cooked dried beans are good choices.

Most people need to drink at least 8 cups of liquid every day. Water and juice with extra water added are good choices.

Your doctor or nurse will order blood tests. If you have anemia, you may need medicine. Or you may need a blood transfusion to help you feel better.

Call your doctor or nurse if you feel:

Dizzy or faint Short of breath

Very weak and tired

Your heart beating very fast

Appetite Changes

"Many days I'm just not hungry. I find it easier to eat small meals. My nurse told me about foods that can help me keep up my strength."

Order this publication: Appetite Changes

Get information about: More chemotherapy side effects

What are appetite changes?

Two common changes during chemotherapy are feeling less hungry and finding that some foods may taste different.

Eat well to help your body stay strong. Let your doctor or nurse know if you lose weight.

Try these tips to make eating easier:

Set meal times and routines.Eat a little, even if you're not hungry.

It may help to eat 5 or 6 small meals each day, instead of 3 large meals. Try new foods to keep up your interest in food.

Eat with family or friends, or watch television while you eat.

Choose healthy foods, like those listed below.

Ask your doctor or nurse about seasonings that may help some foods taste better.

If food tastes like metal, eat with plastic forks or spoons.

Be active.Being active may help you feel more hungry.

Take a short walk each day. Talk with your doctor or nurse about exercise that can help you.

Drink liquids.Getting enough to drink is important, but don't fill up on liquids during meals.

Drink milkshakes or soups that are easy to swallow. Keep track of how much you eat and drink each day. Then talk with your doctor or nurse to

make sure you are eating and drinking enough.

Keep this list on your refrigerator.

Eat more of these foods and drinks that are high in calories or protein.

Ask your doctor or nurse what foods and drinks are best for you.Soups Drinks Main meals and snacks

Cream soups

Soups with lentils or beans (such as black, kidney, pinto, or red)

Some instant breakfast drinks

Milkshakes

Fruit smoothies

Whole milk

Chicken

Lentils or beans (such as black, kidney, pinto, or red)

Eggs

Fish

Nuts, seeds, and wheat germ

Sweets Extras

Custard

Ice cream

Muffins

Pudding

Butter, margarine, or oil added to foods

Cottage cheese, cream cheese, and sour cream

Some liquid meal replacements

Peanut butter

Yogurt (plain or vanilla) Powdered milk added to foods

Constipation

What is constipation?

Are you having bowel movements that come less often than normal for you, are painful, or are hard to pass? This is called "constipation."

Let your doctor or nurse know if you have not had a bowel movement in 2 days or if you have pain in your rectal area.

Take these steps:

Eat high-fiber foods such as:

Whole-grain breads and cereals Fruits and vegetable

Nuts, seeds, and popcornDrink lots of liquids.

Most people need to drink at least 8 cups of liquid every day. Water is a good choice. So are fruit and vegetable juices, such as prune juice.

Warm liquids such as coffee or tea may help.Try to be active every day.

Walk or ride an exercise bike for 15 to 30 minutes a day.

Talk with your doctor to learn about other exercises that can help you.

These foods may help if you are constipated:

Breads and grains Bran muffins

Bran or whole-grain cereals

Brown or wild rice

Cooked, dried peas and beans (such as pinto, black, red, or kidney)

Whole-wheat bread

Whole-wheat pasta and tortillasFruits and vegetables

Dried fruit, such as apricots, dates, prunes, and raisins

Fresh fruit, such as apples, blueberries, and grapes

Raw or cooked vegetables, such as broccoli, corn, green beans, peas, and spinach

Snacks Granola

Nuts

Popcorn

Seeds, such as sunflower

Fatigue (Feeling Weak and Very Tired)To order free copies of this fact sheet, please call 1-800-422-6237 (1-800-4-CANCER).

Why do I feel so tired?

Chemotherapy can make you tired. So can other things like anemia, which is a low red blood cell count. Being depressed or in pain, taking certain medicines, or having trouble sleeping can also make you feel tired.

Make a plan to feel less tired.

Do less. Let others help you. Do activities that are most important first. Ask others for help.

Take time off from your job, or work fewer hours.

Tell your doctor or nurse if:

You are not able to do your normal activities You are still very tired, even after resting or sleeping

Eat and drink well. Make healthy foods when you feel well. Freeze them to eat later. Eat 5 or 6 small meals during the day to keep up your strength, instead of 3 big meals.

Most people need to drink at least 8 cups of water a day. Keep water with you and take small sips during the day.

Be as active as you can. Try to exercise every day. Even 15 to 30 minutes a day can help give you energy. Take a walk or ride an exercise bike every day.

Ask your doctor or nurse about other exercises that can help. Stretching, yoga, or Tai Chi help some people.

Take time to rest. Listen to your body. Rest when you feel tired. Try to take short naps that are 1 hour or less, during the day.

Make a bedtime routine. Bathing or listening to music before you go to sleep may help you relax.

Sleep at least 8 hours every night.

Hair Loss (Alopecia)

Questions other people have asked about hair loss (alopecia):

Why will my hair fall out?Chemotherapy can harm the cells that make hair. This means that hair on your head and anywhere on your body may fall out. Hair loss is called "alopecia."

When will my hair start to fall out?Your hair may start to fall out 2 to 3 weeks after chemotherapy begins.

What can I do before my hair falls out?

"Treat your hair gently."Wash it with a mild shampoo. Pat it dry with a soft towel.

"Cut your hair short."Some people choose to cut their hair short.

"Shave your head."If you shave your head, use an electric shaver so you won't cut your scalp.

"Get a wig."If you plan to buy a wig or hairpiece, get one while you still have hair. This way you can match it to the color of your hair.

It may help to join a support group to talk with others whose hair has fallen out during cancer treatment.

What should I do after my hair falls out?

Protect your head from the sun. Use sunscreen or wear a hat when you are outside.

Protect your head from the cold. Wear a hat or scarf.

Try wearing a soft scarf when you sleep.

When will my hair grow back?

Most likely your hair will grow back in 2 to 3 months after chemotherapy. Sometimes your new hair can be curlier or straighter - or even a different color. In time it may go back to how it was before treatment.

Infection

Take these steps to lower your chances of getting an infection:

Wash your hands well.

Always wash your hands: o Before you cook or eat

o After you use the bathroom

o After being in a public place

Wash your hands well with soap and water.Have people around you wash their hands well, too.

Use hand sanitizer when you can't find soap and water.

Stay extra clean.

Brush your teeth after meals and before you go to bed.Use a very soft toothbrush.

If you have a catheter, keep the area around it clean and dry.Ask your nurse how to take care of this area.

Try to stay away from germs.

Stay away from people who are sick or have a cold.Try to stay away from big crowds if you can.

Wash raw fruits and vegetables.

Wash your hands carefully after you handle raw meat.Cook meat well before eating it.

Try to stay away from people who have just had a chicken pox, polio, or measles vaccine.

Have someone else clean up after your pet.

Try not to get cuts.

Use an electric shaver, not a razor. Clean yourself well and gently after going to the bathroom.

Let your nurse know if your rectal area is sore or bleeds.

Don't squeeze pimples.

Call right away if you have:

Fever that is 100.5° F (38° C) or higher. Ask how many times a day you should take your

temperature. Chills

Cough or sore throat

Ear pain

Headache or bad sinus pain

Stiff or sore neck

Bloody or cloudy urine

Pain or burning when you urinate

Skin rash

Sores or white coating in your mouth or on your tongue

Swelling or redness anywhere. Watch for swelling or soreness if you have a catheter.

Pain

To order free copies of this fact sheet, please call1-800-422-6237 (1-800-4-CANCER).

It's important to treat pain.

If you find that you are in pain, don't put up with it. There are many medicines to help lower or get rid of pain. Talk with your doctor to learn about medicine that can help you. Ask what other things, like massage or acupuncture, could also help. Remember, being in less pain will help you feel stronger and better.

"I was worried about getting addicted to pain medicine. Then I talked with my doctor. She told me that treating pain is an important part of good cancer treatment. So now I take my pain medicine on time and am able to enjoy life more!"

Call the doctor or nurse if:

The pain isn't getting better or going away

The pain comes on quickly

The pain makes it hard to eat, sleep, work, or play

You feel new pain

The pain medicine is not working as fast or for as long as it used to

Tips to get the most out of your pain medicine:

Ask how much pain medicine to take. Take the right amount of medicine each time you are supposed to.

Ask when to take the pain medicine. Take the pain medicine on time. If you take the pain medicine too late, it may not work as well.

Tell your doctor or nurse if the pain does not go away after you take the medicine.

Tell your doctor or nurse if you are in pain, but it's not yet time to take the pain medicine.

Don't stop taking the pain medicine unless your doctor tells you to.

Talk with your doctor, nurse, or social worker if you need help to pay for pain medicine.

Give your doctor or nurse a list of all of the medicines you are taking.

Keep track of the pain.

Each day, write about any pain you feel. This will help you talk with your doctor or nurse. Use a notebook or separate piece of paper to fill in the information below.

1. The pain is dull, sharp, burning, shooting, throbbing, or:

(Add your own words if these don't describe the pain you feel.)

2. On a scale of 1 to 10, where "10" is the most pain and "1" is the least pain, I feel this much pain:

3. I feel the most pain when:

4. Things I can't do because of the pain:

5. This makes the pain feel worse:

6. This makes the pain feel better:

Tell your doctor or nurse if you:

Feel sick to your stomach

Feel sleepy

Have constipation or dry stools

If these problems don't go away on their own after a few days, they can usually be treated.

You may need more or different pain medicine.

It is normal for your body to get used to the pain medicine. It may not work as well as it did at first. This is called "tolerance." It happens to many people. If this happens to you, your doctor may change your pain medicine or change the way you take it.

You will not get addicted when cancer pain medicines are given and taken in the right way. Don't be afraid to ask for more pain medicine if you're still in pain.

Skin and Nail Changes

To order free copies of this fact sheet, please call1-800-422-6237 (1-800-4-CANCER).

Let your doctor or nurse know if:

Your skin is itchy, dry, red, or hurts

Your nails are dark, yellow, or cracked

Call your doctor or nurse if:

You develop sudden or severe itching

Your skin has a rash or hives

For minor skin problems:

Be careful what you put on your skin.

Use only mild soaps that are gentle on your skin.

Use lotions and creams. Ask your nurse when to use them.

Don't use products on your skin that have alcohol or perfume in them.

Ask what products or brands you should use on your skin.

"I was glad to learn that most skin and nail problems go away after treatment. For now, my nurse told me about a lotion to help my skin feel better."

Protect your skin from the sun.

Try to stay out of the sun.

When you are outside, always wear sunscreen and lip balm. Or wear a long-sleeved shirt, pants, and a hat with a wide brim outdoors.

Don't use tanning beds.

Treat your skin gently.

It may help to take short showers or baths in warm water. Don't take long baths in hot water. Pat your skin dry instead of rubbing it.

Dusting your skin with cornstarch may help. Put it in the folds of your skin such as under your arms, behind your knees, and under your breasts.

Shave less often, or stop shaving if your skin is sore.

For minor nail problems:

Keep your nails clean and cut short. Check with your nurse before you get a manicure.

Wear gloves when you wash the dishes, work in the garden, or clean the house.

Check with your nurse for products that can help your nails.