Objectives Address common questions and/or myths that patients who have leukemia or their support persons may have Share research-based information and recommendations Provide reputable resources for future information
Sex Two separate issues –Fertility Birth control during treatment: important to use even if infertility is a likely side effect of your treatment –Intimacy A little more complicated…
Sexual Relationships & Intimacy Why talk about it? Sex is good –Desire Increase in dopamine, “excited” feeling –After orgasm Increase in prolactin –Calming Increase in oxytocin –Trust, sense of affiliation, “cuddling hormone” Increase in endorphins –Euphoria, inhibit transmission of pain signals
Sexual Relationships & Intimacy Why talk about it? Research tells us… –A problem exists Bone Marrow Transplantation, (1999) –30% reported no participation in sexual activities Blood, (2008) –Up to 80% reported some type of sexual problem 2-5 years post treatment –Patients care about sex Journal of Advanced Nursing, (1997) –One of patients’ biggest reported problems was decreased sexual energy
Sexual Relationships & Intimacy “Can I have sex?” No randomized controlled trials Best guidance based on what we know about disease, treatment effects, etc., focused on safety
“Can I have sex?” Conversation between patient and healthcare team. “What does that mean to you?” Consider your: –Treatment –Partner –Side effects
Consider Your Treatment Chemotherapy –Excreted in body fluids during treatment days and 48 hours after treatment is completed Use a condom for penetration or oral sex to prevent partner from exposure Ok to have sex with a central line
Consider Your Partner Know your partner –Stable partner who does not have other partners is best –“Casual sex” not a good idea Sexually Transmitted Infections –Note any sores, bumps, warts, or white/greenish fluid on partner’s genitals. –No sex until you confirm it is not an STI.
Consider Your Side Effects Low blood counts –Potential for infection or bleeding with vaginal or anal penetration Use condoms Liberal use of water-based lubricant –Do NOT use lotion, oil, or petroleum jelly – weakens latex condoms –Potential for infection with oral sex Use plastic film or dental dams –Herpes simplex virus and genital warts can flare during periods of neutropenia
Consider Your Side Effects Fatigue –Try different positions Premature menopause due to chemo –Results in vaginal dryness, which may lead to painful intercourse Vaginal moisturizers Lubricant Hormone replacement therapy Give yourself time
Reputable Resources A Woman’s Touch –Store in Madison, WI –Free phone consultations – –https://sexualityresources.comhttps://sexualityresources.com
Food & Nutrition Why talk about it? Recommendations have changed over time Food is something patients can control
Where did the “neutropenic (or low bacteria) diet” come from? 1960s & 1970s: Patients with leukemia placed in total protective environment were found to tolerate higher doses of chemo with less toxicity 1978 & 1982: Organisms common for causing infections in patients identified on food 1987 & 1993: Showed bacteria can move from gut to bloodstream Basis for the Low Bacteria Diet Many variations from sterile to modified regular
What have we learned in the last decade? 2006: Outpatients receiving chemo, neutropenic diet versus regular diet –No difference in hospital admissions due to fever or infection 2007: Inpatient ALL & AML, antibiotics + low bact diet versus antibiotics + regular diet –No difference in infection rates or stool samples 2008: Inpatient AML receiving induction, cooked versus raw diet –No difference in infection or mortality rates 2012: Cochrane Review determined “no evidence of effect” for the Low Bacterial Diet
“What can I eat?” Probably should be “What can’t I eat?” Foods to generally avoid: No raw eggs, meat, fish, or milk Beware soft cheeses No foods containing mold (i.e. blue cheese) Do not drink untested or unboiled well water Your doctor may ask you to avoid other foods if your condition warrants.
“What can’t I eat?” Basic Infection Control Wash hands often. Wash all foods. Be mindful of where you eat. –Buffets, salad bars, restaurants where you are unsure of food prep Clean kitchen tools, cutting boards often. Launder kitchen towels frequently. Basic Food Safety Check expiration dates. Hot food stays hot, cold food stays cold. Separate and don’t cross- contaminate. Refrigerate leftovers promptly. Cook meats well done. –Use a meat thermometer to assure safe temps.
Reputable Resources National Cancer Institute’s Food Safety Guide American Cancer Society American Institute for Cancer Research
Food Myths “Does sugar feed cancer?” Fact: All cells in our body depend on glucose (sugar) for fuel. Glucose comes from food containing carbohydrates, which includes fruits, vegetables, grains, dairy, and refined sugar. There is no direct connection between sugar and cancer growth. –Hauner H, Bechthold A, Boeing Het al. (2012) –World Cancer Research Fund & American Institute for Cancer Research, (2007). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. World Cancer Research Fund: Washington, DC. Eating a lot of refined sugars add empty calories, which can lead to excess weight and body fat.
Food Myths “Should I only eat organic foods?” Fact: Fruits and vegetables are part of a healthy diet. Organically grown foods are likely to have lower pesticide residues. No studies show conventionally grown vegetables increase cancer risk. Organic food information: –Dirty Dozen Plus 2 –Clean Fifteen –Find more information from the Environmental Working Group
Edible THC THC = tetrahydrocannabinol, the active ingredient in marijuana Literature supports consideration for use in chemotherapy-induced nausea and vomiting and appetite stimulation in the cancer population –Cotter (2009) –Nelson, Walsh, Deeter, & Sheehan (1994) Smoking marijuana strongly discouraged due to plant matter containing molds Pharmaceutical, FDA-approved THC safest More information needed re: edibles
Vaccines Why talk about it? Fairly controversial topic Guidelines exist, but may conflict Two major questions –“Do vaccines cause leukemia?” –“If I have leukemia, can I be vaccinated? Can my family be vaccinated?”
“Do vaccines cause leukemia?” Research says…NO! –2005: International Journal of Epidemiology, study done re: vaccination history and risk for childhood leukemia Findings: MMR, DTaP/Tdap – no difference in risk. Hib (haemophilus B influenzae) – assoc. with less risk –2008: American Journal of Epidemiology, 4 year longitudinal study Findings: No association between vaccine administration and development of leukemia
“If I have leukemia, can I be vaccinated? Can my family be vaccinated?” Complicated question Issue: Patients with cancer have a significant need for protections vaccines provide, but the vaccine may not work as well. –Studies : Patients with leukemia undergoing treatment had decreased titers (reduced response) compared to immunocompetent persons No evidence that vaccines are harmful Few studies, small sample sizes
“If I have leukemia, can I be vaccinated? Can my family be vaccinated?” Guidelines –Infectious Diseases Society of America (IDSA) –Centers for Disease Control & Prevention (CDC) Clinician Challenges –Optimal timing not clearly defined –Unpredictable durability: main determinant is level of immediate immune response –Avoid live vaccines
“If I have leukemia, can I be vaccinated?” IDSA 2013 Guidelines Flu vaccine –Recommend unless unlikely to respond Differs from CDC – states give to all Pneumococcal vaccine –PCV13: for all newly diagnosed adults and children –PPSV23: at least 8 weeks after dose(s) of PCV13 Children’s normal vaccination schedule –3 months after chemotherapy vaccinate with inactive vaccines & live, attenuated vaccines for MMR & varicella
“Can my family be vaccinated?” IDSA 2013 Guidelines Individuals who live with immunocompromised persons should receive: –Annual influenza vaccine –Other vaccines as scheduled Except oral polio vaccine
Reputable Resources To learn more about vaccinations, go to: Centers for Disease Control & Prevention Infectious Diseases Society of America
Contact Information Jayme Cotter, MS, RN, AOCNS, ACNS-BC Clinical Nurse Specialist Froedtert & Medical College of Wisconsin Clinical Cancer Center Phone:
References Cotter, J. (2009). Efficacy of crude marijuana and synthetic delta-9-tetrahydrocannibinol as treatment for chemotherapy-induced nausea and vomiting: A systematic literature review. Oncology Nursing Forum, 36(3): DeMille, D., Deming, P., Lupinacci, P., & Jacobs, L. A. (2006). The effect of the neutropenic diet in the outpatient setting: a pilot study. Oncology Nursing Forum, 33(2): Gardner, A., Mattiuzzi, G., Faderl, S., Borthakur, G., Garcia-Manero, G., Pierce, S., Brandt, M., & Estey, E. (2008). Randomized comparison of cooked and noncooked diets in patients undergoing remission therapy for acute myeloid leukemia. Journal of Clinical Oncology, 26(35): Hauner, H., Bechthold, A., Boeing, H., Bronstrup, A., Buyken, A., Leschik-Bonnet, E., Linseisen, J., et al. (2012). Evidence-based guideline of the German Nutrition Society: Carbohydrate intake and prevention of nutrition-related diseases. Annals of Nutrition and Metabolism, 60(supp1): Hjermstad, M. J., Holte, H., Evensen, S. A., Fayers, P. M., & Kaasa, S. (1999). Do patients who are treated with stem cell transplantation have a health-related quality of life comparable to the general population after 1 year? Bone Marrow Transplant, 24: Ma, X., Does, M. B., Metayer, C., Russo, C., Wong, A., & Buffler, P. A. (2005). Vaccination history and risk of childhood leukaemia. International Journal of Epidemiology, 34(5): MacArthur, A. C., McBride, M. L., Spinelli, J. J., Tamaro, S., Gallagher, R. P., & Theriault, G. P. (2008). Risk of childhood leukemia associated with vaccination, infection, and medication use in childhood. American Journal of Epidemiology, 167(5): Moody, K., Charlson, M. E., & Finlay, J. (2002). The neutropenic diet: What’s the evidence? Journal of Pediatric Hematology/Oncology, 24(9):
References Mumma, G. H., Mashberg, D., & Lesko, L. M. (1992). Long-term psychosexual adjustment of acute leukemia survivors: Impact of marrow transplantation versus conventional chemotherapy. General Hospital Psychiatry, 14: Nelson, K., Walsh, D., Deeter, P., & Sheehan, F. (1994). A phase II study of delta-9-tetrahydrocannabinol for appetite stimulation in cancer-associated anorexia. Journal of Palliative Care, 10(1): Persson, L., Hallberg, I. R., & Ohlsson, O. (1997). Survivors of acute leukaemia and highly malignant lymphoma – retrospective views of daily life problems during treatment and when in remission. Journal of Advanced Nursing, 25: Porter, C., Edwards, K., Zhu, Y., & Frangoul, H. (2004). Immune responses to influenza immunization in children receiving maintenance chemotherapy for acute lymphoblastic leukemia. Pediatric Blood Cancer 42(1): 36–40. Rubin, L. G., Levin, M. J., Ljungman, P., Davies, E. G., Avery, R., Tomblyn, M., Bousvaros, A., et al. (2013) IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clinical Infectious Diseases. Oxford University Press, pg Sinisalo, M., Aittoniemi, J., Oivanen, P., Kaeyhty, H., Oelander, R., Vilpo, J. (2001). Response to vaccination against different types of antigens in patients with chronic lymphocytic leukaemia. British Journal of Hematology, 114: Syrjala, K. L., Kurland, B. F., Abrams, J. R., Sanders, J. E., & Heiman, J. R. (2008). Sexual function changes during the 5 years after high-dose treatment and hematopoietic cell transplantation for malignancy, with case- matched controls at 5 years. Blood, 111:
References van Dalen, E. C., Mank, A., Leclercq, E., Mulder, R. L., Davies, M., Kersten, M. J., & van de Wetering, M. D. (2012). Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia (review). The Cochrane Library, 9: van Tiel, F. H., Harbers, M. M., Terporten, P. H. W., van Boxtel, R. T., C., Kessels, A. G., Voss, G. B. W. E., & Schouten, H. C. (2007). Normal hospital and low-bacterial diet in patients with cytopenia after intensive chemotherapy for hematological malignancy: a study of safety. Annals of Oncology, 18: World Cancer Research Fund & American Institute for Cancer Research, (2007). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. World Cancer Research Fund: Washington, DC.