Side Effects of Breast Cancer

Many cancer patients report issues during and after cancer treatment including:

• memory loss
• forgetfulness
• loss of concentration
• confusion

These side effects result from changes in the cognitive (thinking) processes of the brain. Even though these side effects are commonly referred to as “chemo brain,” factors other than chemotherapy can lead to cognitive side effects such as:

• brain cancer or brain metastasis
• brain surgery
• radiation to the brain
• medications
• fatigue
• anemia
• hypothyroidism
• stress and anxiety

Cognitive side effects can be short term or long term. This depends on the cause of the side effects, the age of the patient, and the overall health of the patients. If the cause is medication, once the medication is stopped, cognitive issues should improve. If surgery or radiation damages the brain or nervous system, the side effects may not improve over time.

Delirium is a severe cognitive issue indicated by loss of awareness and memory, drastic changes in behavior and judgment, and lack of muscle control. Delirium can be dangerous if the person is left alone. Delirium is most likely to occur in advanced cancer patients or near end of life.

Cognitive issues present many challenges. Because the direct cause of cognitive issues can be unclear, they are difficult to treat. Healthcare professionals are still researching cognitive issues as they relate to cancer and cancer treatment.

Changes in memory and brain function can be distressing, but many patients share the same experience. There are some things you can do to manage cognitive side effects.

Plan Ahead

• Write to-do lists.
• Keep a detailed calendar of appointments and other important dates.
• Leave notes around the house to remind yourself to do things.
• Track your medications and use a weekly pill box.
• Lay out everything you need for the day the night before.
• Use your phone to set reminders.

Get Organized

• De-clutter your home and your workspace.
• Make sure everything has a place.
  • Put keys in bowl by the door every day.
  • Leave your cell phone on your nightstand.
• Use labels for storage areas and boxes.

Minimize Distractions

• Avoid multitasking; focus on one task at a time.
• Put your phone and other unnecessary electronic devices away when working.

Exercise Your Brain

• Do “brain exercises” by taking free online quizzes or playing along with game shows.
• Try Sudoku or crossword puzzles.
• Read.
• Learn a new hobby such as painting or writing.

Exercise Your Body

• Exercise is not only good for your body. It can make you feel better mentally, too. Exercising releases mood-boosting endorphins.
• Exercise also combats fatigue, which can contribute to cognitive issues.
• Try going for a daily walk or taking an exercise class.
• Ask your healthcare team before beginning any exercise program.

Eat Well

• Choose foods that promote healthy brain functioning such as fish (omega-3 fatty acids), dark leafy greens, fresh fruits and vegetables, and whole grains.
• Avoid alcohol and other substances that alter cognition.

Get Plenty of Rest

• Being tired can make you less focused.
• Fatigue and insomnia are common side effects of cancer treatment.

Check Red Blood Cell Counts

• Anemia is a condition that occurs when the body does not have an adequate amount of red blood cells.
• Anemia can cause cognitive issues.
• Ask your healthcare team to check your red blood cell counts if they are not doing so already.

De-Stress

• Anxiety and stress can cause or worsen cognitive issues.
• Try to relax in a way that works for you. Consider trying:
  • Deep breathing
  • Meditation
  • Taking a warm bath
• Your doctor may be able to prescribe medication to help with anxiety and depression.
• Try seeking emotional support from a support group or one-on-one partnering organizations.

Ask for Help

• Be honest with your friends and family about your “chemo brain.”
• If you explain what you are going through, they can be more understanding.
  • They can also help you manage your side effects by sending you friendly reminders or helping you organize your space.
• As always, talk to your healthcare team about your side effects and ways to manage them.

Constipation is common during cancer treatment. It can be caused by many factors such as cancer type, food and liquid intake, surgery, or medications. Follow these tips to manage constipation and promote regularity.

• Soluble and insoluble fiber are both important for overall health and nutrition.
  • Soluble fiber is found in oats, beans, sweet potatoes, and fruits.
  • Soluble fiber is completely digested by the body. Soluble fiber reduces cholesterol, stabilizes blood sugar, and rids the body of toxins.
  • Insoluble fiber is found in wheat, nuts, seeds, and fruit and vegetable skins.
  • Insoluble fiber is not digested by the body and is excreted as waste. Insoluble fiber promotes regularity.
• Drink plenty of liquids.
  • Fluid helps your body process fiber without discomfort. A good starting goal is eight 8-ounce glasses of fluid per day.
• Gradually increase your fiber intake.
  • Your daily goal should be between 25-35 grams daily.
  • Fiber is mostly found in plant foods, such as fruits and vegetables, beans, legumes, whole grain cereals, breads, and oatmeal.
• Eat 3-5 servings of fruits and vegetables daily.
  • Choose whole fruit instead of juice.
  • Eat the skins and seeds for extra fiber.
  • Try to have a fruit or vegetable with each meal or snack.
• Choose foods that promote regularity.
  • Eat cereals, breads, and pastas that are made with 100% whole grain.
  • Have brown or wild rice in place of white rice or potatoes.
  • Choose hot cereals like oatmeal or cold cereals with at least 5 grams of fiber.
  • Choose whole wheat breads, whole corn or wheat tortillas, and whole grain crackers instead of refined products.
  • Eat more beans, lentils, and peas. Add them to soups and casseroles, or have them as a main entrée.
  • Beans are also a great source of protein, so you can use them as a substitute for meat at mealtimes.
  • Beans can be gas forming, so add them gradually. If you experience bloating or discomfort, you may want to limit them in your diet.
• Try plum or prune juice.
  • Start with a small amount such as a ½ cup.
  • Eating dried prunes may also help relieve constipation.
• Try to include exercise or physical activity in your daily routine.
  • Physical activity is a natural way to help constipation.
  • Always discuss any exercise or physical activity with your healthcare team before making changes.
• Talk to your healthcare team about medication or supplements to help with constipation.
  • There are over the counter medications that may help with constipation but you should always check with your doctor first before taking anything.

Diarrhea occurs when foods pass through the body too quickly. The body cannot absorb enough nutrients, vitamins, minerals, and water. Follow these tips to carefully manage diarrhea and prevent dehydration and malnutrition.

• Contact your healthcare team for advice managing diarrhea.
  • If you have sudden diarrhea, have diarrhea for more than 24 hours or are experiencing pain, cramping, or blood in your stools, call your healthcare provider immediately.
  • Take medications or supplements only if they are recommended by your healthcare team.
  • Always ask your healthcare team first before taking anti-diarrhea medications.
  • Always talk to your healthcare team or a dietitian before taking any supplements.
• Stay hydrated to replace fluid losses.
  • Be sure to drink plenty of clear liquids (water, ginger ale, sports drinks, or electrolyte replacement drinks) for 12 to 24 hours after a sudden bout of diarrhea.
  • Make a homemade electrolyte replacement drink by mixing the following ingredients: ¼ teaspoons salt, 8 teaspoons sugar, 3 tablespoons orange juice concentrate, and 4 cups water.
  • Let carbonated drinks lose their fizz before you drink them.
  • Drinking clear liquids helps the bowel rest and replaces lost fluids.
  • Healthy people need a minimum of 8 cups of liquid per day. You may require more to replace fluids lost with diarrhea.
• Eat 5 or 6 small meals per day instead of 3 larger meals.
  • Eating smaller meals may put less stress on your bowels and will make it easier for your body to digest food.
• Choose foods and drinks carefully.
  • Very cold foods and very hot foods can make diarrhea worse.
  • If your diarrhea gets worse after eating a certain food, stop eating that food until you recover.
  • Avoid foods and drinks that can make your diarrhea worse. High fiber foods, raw fruits and vegetables, full-fat dairy products, foods and drinks that contain caffeine, and spicy or high-fat foods can make diarrhea worse.
  • Choose foods that help manage diarrhea, like white rice, puffed rice cereal or other low-fiber grains, soft fruits like bananas and applesauce, cooked soft vegetables, and low-fat meats and dairy products.

Treatment to the head and neck can make swallowing difficult and painful. This may make it hard to eat well and maintain a healthy weight. Follow these tips to make swallowing easier.

• Chemotherapy or radiation to the head and neck can harm the cells that line the throat and cause discomfort.
  • Higher doses of radiation can cause more discomfort.
  • Chemotherapy and radiation treatment at the same time may make side effects worse.
  • Drinking alcohol or using tobacco can make side effects worse.
• Use mealtime tactics to make swallowing easier.
  • Eat 5 or 6 small meals each day instead of 3 large meals. It may be easier to eat a smaller amount of food at one time.
  • Cook foods until they are soft and tender.
  • Moisten and soften foods with gravy, sauces, broth, or yogurt.
  • Consume liquids with meals.
  • Sip drinks through a straw; this may make them easier to swallow.
• Avoid foods that are hard to swallow or irritating.
  • Avoid coarse foods that do not soften in the mouth.
  • Avoid sharp and crunchy foods like potato and tortilla chips.
  • Avoid spicy foods.
  • Avoid acidic foods like lemons, lime, oranges, and tomatoes.
  • Be careful eating hot foods to reduce the risk of burning your mouth. Cold foods may be soothing.
  • Avoid alcohol.
• Choose foods that are easy to swallow.
  • Try breakfast foods like instant oatmeal, grits, pancakes, waffles, and cold cereal that has been softened in milk.
  • For a main dish, try chicken, tuna or egg salad, soups and stews, soft cooked fish, tofu, and meatloaf.
  • Pick side dishes like cottage or ricotta cheese, macaroni and cheese, mashed white or sweet potatoes, and rice or risotto.
  • Try desserts like custard, tapioca pudding, ice cream, milkshakes, and sherbet.
  • Choose snacks like creamy nut butters, applesauce, gelatin, smoothies, and yogurt.

When cancer treatments fight cancer cells, they can also affect healthy cells. This can result in certain side effects including skin changes. Side effects of the skin commonly occur with two cancer treatments: external beam radiation therapy and new targeted therapies.

External Beam Radiation Therapy

With external beam radiation therapy, high-energy radiation rays from outside the body are used to kill and shrink cancerous tumors. The radiation is targeted at a specific area of the body. This therapy usually consists of daily treatments over several weeks.

Skin side effects, such as the following, do not usually appear until about the third week of treatment and may continue after finishing treatment:

• The skin at the treatment area may become red, dry, and tender like a mild to moderate sunburn.
• The skin may also become very itchy, which is a condition called pruritus.
• In some cases, the skin may even darken, swell, blister, or peel away.
• If the skin becomes moist or cracked, you are at risk for an infection.

If side effects become too severe, your radiation oncologist may stop or delay treatment to allow your skin to rest.

How can I manage my skin side effects?

First, always tell your healthcare team about any skin changes you notice. Some side effects can be easily managed with prescription creams or oral medications.

Avoid irritants.

• Use unscented bath and household products including soap, shampoo, lotion, detergent, and dryer sheets.
• Do not use bath products containing alcohol. Alcohol dries the skin, making irritation worse.
• If your facial skin is affected, avoid using makeup, or switch to a sensitive skin brand.
• Always wear gloves when cleaning, and avoid skin contact with cleaning products.
• Do not shower or bathe with extremely hot or extremely cold water.
• Stay out of the sun, or wear protective clothing and sunscreen if you must be outside.
• Do not use tanning beds.
• Do not use chlorinated pools or hot tubs.

Let your skin rest.

• Do not scratch or pick at your skin.
• Do not pop blisters.
• Wash skin with care.
• Use a mild, fragrance-free soap.
  • Do not scrub the skin.
  • Let warm (not hot) water gently run over the affected area.
• Do not wear tight clothing over the affected areas.
• Do not use adhesive bandages.

Moisturize.

• Keep skin well moisturized.
• Use petroleum-based skin protectants or unscented lotions.
• Look for moisturizers specifically for sensitive skin.
• Ask your doctor which over-the-counter moisturizer is best for you.
• Use a humidifier while you sleep, and keep the temperature cool.
• If you are having radiation treatment, do not apply moisturizers right before treatment. It's better for your skin to be clean and clear during actual treatments.

Watch for signs of infection.

• Signs of infection include:
  • swelling, redness, or warmth
  • cloudy drainage or pus instead of clear
  • fever
  • bad smells
• Tell your doctor immediately if you notice signs of infection. You may need an antibiotic. If left untreated, infections can become very serious and spread to other parts of the body.

Dry mouth is common during and following cancer treatment. Symptoms of dry mouth are thirst, sore mouth or throat, difficulty swallowing, and changes in taste. Follow these tips to manage dry mouth.

• Chew gum or suck on ice chips, hard candy, or popsicles to help relieve dry mouth.
  • Keeping gum, ice chips, candy, or popsicles in the mouth helps keep the mouth moist.
  • Choose sugar-free or low-sugar gum or candy for prevention of cavities.
  • In place of ice chips, try frozen grapes.
  • Use lip balm if your lips become dry.
• Choose foods that are easier to chew and swallow.
  • Choose soft foods like scrambled eggs, puddings, and ice cream.
  • Avoid dry foods.
  • Cut your food into small pieces to make it easier to chew and swallow.
  • Soups and stews are good options, as long as meats are soft or cut into small pieces.
  • Try mashed potatoes and rice instead of crackers or breads.
  • Choose canned fruits or applesauce instead of raw fruits.
  • Puddings, ice cream, and sorbet are also good options.
  • Serve foods with gravy, broths, or sauces. This will make them easier to chew and swallow.
  • Season your food with citrus and herbs instead of salt or hot spices.
• Drink at least eight to ten 8-ounce cups of liquid each day.
  • Drinking liquids with meals can make it easier to swallow foods.
  • Sip cool drinks in between meals to ensure adequate fluid intake.
  • Tart drinks in small amounts, such as lemonade, may help your mouth produce more saliva.
  • Keep a glass of water next to your bed at night. Drink when you wake during the night.
• Eat small meals, and eat more often.
  • Eating small, frequent meals will ensure that you are meeting your nutritional needs.
  • Try to have a good source of protein with meals and snacks. Eggs, cottage cheese, yogurt, beans, lentils, and smoothies are good soft food choices that also provide protein.
• Promote a moist mouth.
  • Rinse your mouth every 1-2 hours.
  • Mix ¼ tsp. of baking soda and 1/8 tsp. salt with 1 cup warm water. Rinse with plain water after using this mixture.
  • Do not use a mouthwash that has alcohol. Alcohol makes a dry mouth worse.
  • Ask your doctor if an artificial saliva product might help. Radiation and some medications can decrease saliva production.
• Avoid things that make dry mouth worse.
  • Alcoholic drinks can worsen dry mouth.
  • Do not smoke or use other tobacco products.
  • If you do smoke, talk to your healthcare team about quitting.
• Tell a doctor or nurse if you have white patches in your mouth.
  • White patches can be evidence of an infection.

Fatigue impacts quality of life and can make it hard to eat healthy meals. The body needs proper nutrition to function. Improper nutrition can make other side effects worse. These tips can help manage fatigue.

• Cancer-related fatigue primarily occurs because the body requires additional energy to heal.
  • Other side effects, medications, and stress can make fatigue worse.
• While rest is important, too much rest can make you feel more tired so stay as active as possible.
  • Try going for a daily walk.
  • Talk to your healthcare team before beginning any exercise program.
• Go no longer than 4-5 hours without eating throughout the day.
  • Try to eat a balanced breakfast every day.
  • Try to eat small meals and snacks rather than large meals.
• Eat foods that provide sustainable energy; avoid foods that do not.
  • Try to include a source of protein at every meal to sustain energy released from food.
  • Try to limit sweets and sugary foods.
  • Avoid alcohol, caffeine, and chocolate in the evening.
• Stay hydrated by drinking liquids throughout the day.
• Stock your kitchen with easy-to-prepare foods and meals.
  • Ask your family and friends to help you shop for food and prepare meals.
  • Prepare food when you feel your best, and save it for later.
  • Prepare large amounts of your favorite meals then freeze meal-sized portions for later.
• Try keeping a food and fatigue journal to find patterns that trigger fatigue.
• Discuss fatigue with your healthcare team.
  • Ask your doctor to check for nutrient deficiencies, such as protein, iron, B vitamins, and vitamin D.
  • Talk to your healthcare team about other side effects such as anemia, pain, or vomiting.

Feeling full too quickly is a common side effect, especially after abdominal surgery. This can cause weight loss. Not eating enough weakens the body and delays healing. Below are some tips to ensure proper nutrition.

• Eat small, frequent meals throughout the day.
  • Smaller meals are easier to digest and will allow you to better meet your needs throughout the day.
  • Keep healthy snacks on hand to eat between scheduled meals.
• Avoid foods and actions that may cause gas or bloating.
  • High-fat foods take longer to digest. They can make you feel fuller between meals. Avoid fried or greasy foods.
  • Gas-forming foods include: broccoli, cauliflower, Brussels sprouts, cabbage, corn, turnips, onions, peas, garlic, cantaloupe, watermelon, apples, avocado, beans, lentils, and nuts.
  • Stop behaviors that involve swallowing extra air. Do not suck on ice or candy, chew gum, drink carbonated drinks, or drink through a straw.
• Drink liquids between meals rather than during meals.
  • Drinking with your meals and snacks can fill you up more quickly.
  • Avoid carbonated drinks. Carbonated drinks can make you feel fuller.
• Keep your head up after meals.
  • Lying down after meals will only make your discomfort worse.
• If you are underweight or losing weight too quickly, choose foods that are rich in nutrients and calories.
  • Try to have a source of protein with each meal and snack. Some examples of protein-rich foods include eggs, chicken, fish, meat, milk, yogurt, cheese, beans, nuts, and peanut butter.
  • Add extra calories, protein, and healthy fats to foods you already eat to help prevent weight loss. Try adding olive oil, nuts, nut butters, seeds, non-fat powdered milk, or protein powder to recipes.
  • Drinking nutrient-rich liquids like smoothies or milkshakes can provide nutrition without making you feel full. Liquids leave the stomach more quickly than solid foods.
  • Ask a registered dietitian if drinking a liquid nutrition supplement is needed to provide necessary calories and protein. If needed, a specific liquid nutrition supplement can be recommended that meets your needs.

Excess gas is a common side effect, especially for colorectal and stomach cancer patients. Foods, drinks, behaviors, and medications contribute to gas. These tips may help with the pain, bloating, and discomfort that come with excess gas.

• Avoid gas-forming foods.
  • Avoid broccoli, cauliflower, Brussels sprouts, cabbage, corn, turnips, onions, peas, peppers, radishes, garlic, cantaloupe, watermelon, apples, avocados, beans, lentils, and nuts.
  • Avoid dairy products such as milk cheese or yogurt.
  • Avoid carbonated beverages.
• Avoid behaviors that cause you to swallow extra air.
  • Eat slowly.
  • Do not suck on ice or candy.
  • Do not chew gum.
  • Do not drink through a straw.
  • Drink liquids slowly with small sips.

What is hypothyroidism?

Hypothyroidism means your body is not making enough of the thyroid hormone. The thyroid hormone regulates your metabolism. Metabolism is the internal process that allows your body to use food and nutrients and produce and use energy. Hypothyroidism may occur for many reasons, including as a result of cancer treatment or surgery that affects or removes the thyroid gland.

What are the side effects of hypothyroidism?

The side effects of hypothyroidism include:

• Fatigue
• Difficulty sleeping
• Sleeping too much
• Puffiness (often in the face) and bloating
• Loss of concentration, memory loss, absentmindedness.
• Weight gain
• Anxiety, irritability, mood swings
• Depression
• Dry eyes and mouth
• Dry or flaky skin
• Inability to process nutrients used by the body, such as calcium
• Hair loss or thinning
• Changes or interruptions to menstrual cycle
• Joint pains and stiffness
• Muscle cramps
• Intolerance to cold
• Constipation
• Nausea
• Tingling or numbness in fingers or toes (neuropathy)

Remember, these side effects are temporary. Once you begin taking a thyroid hormone (levothyroxine, sold under the brand names Synthroid and Levoxyl), your side effects will gradually improve.

What can I do to manage hypothyroidism?

• Take your medication as directed.
  • It is important to take your thyroid hormone as directed by your doctor, usually on an empty stomach at the same time every day.
  • It is usually recommended that you not take supplements for a period of time after taking thyroid hormone. Antacids, iron, and calcium supplements, dietary fiber, soy, and even walnuts can affect your body's absorption of the hormone. Check with your doctor or pharmacist for more specific recommendations.
• Eat a healthy diet.
  • Proper nutrition will help you fight fatigue, prevent unwanted weight gain, and promote healthy hair and skin.
  • Your calorie needs may change as your thyroid hormone levels change, and therefore you may find it helpful to talk with a Registered Dietitian for guidance.
• Get active.
  • Physical activity can improve quality of sleep, increase energy, treat constipation, prevent unwanted weight gain, and alleviate feelings of depression or anxiety.
  • Ask your healthcare team before starting any exercise program.
• Go easy on yourself.
  • You may feel frustrated by fatigue and absentmindedness, but remind yourself that these side effects won't last forever.
  • Once you begin taking levothyroxine, it may take months for the body to re- regulate itself; try not to get discouraged.

Many cancer patients report that they occasionally have trouble sleeping or that they can't sleep at all (insomnia). Lack of sleep can lead to other issues such as fatigue, loss of concentration, headaches, and irritability.

To minimize the impact of insomnia, focus on these three possible solutions: managing other side effects of cancer or treatment, creating a good sleep routine, and talking to your healthcare team.

Manage other side effects.

Some side effects of cancer treatment can lead to difficulty sleeping. If you can minimize those side effects, then your sleep may improve.

Nausea
Nausea may make it difficult for you to go to sleep, and vomiting may wake you up at night.

• Sleeping with your head slightly elevated may help you get more comfortable.
• If your doctor has prescribed medication for nausea, make sure you take it as recommended, especially before bedtime.

Pain
Any type of pain can keep you up at night and make it difficult to be comfortable.

• Make sure you take pain medication as recommended, especially before bedtime.

Weight Gain
If you gained weight as a result of cancer treatment, you may have trouble falling asleep and staying asleep. The extra weight can make it difficult to get comfortable. It can also make sleeping more difficult because your body has to work a little harder to function normally, such as regulating breathing.

• Try using a body pillow to give you more sleeping positions.

Hormonal Changes
Hormonal changes, such as menopause for women, can disrupt sleep, especially with side effects such as hot flashes and night sweats. Talk to your healthcare team about the best ways to manage hormonal changes. Your doctor may be able to prescribe medications to help manage hormonal changes.

• Cool temperatures can help promote sleep. Make sure your bedroom thermostat is set low and that your pillowcase feels cool to your skin.
• If night sweats are a problem, buy wicking sleepwear to keep you dry at night.

Stress and Anxiety
Stress and anxiety can keep you up at night. It may feel difficult to “turn off your brain.” Finding ways to cope with your stress and anxiety is very important.

• Enjoy a relaxing activity every night before bed to take your mind off cancer. Try working on a crossword puzzle, reading a book, or listening to music.
• Try simple stretches, yoga, or meditation to clear your mind.

At any point in your cancer journey, you may wish to seek emotional support. Support groups, peer matching programs, or individual counseling may help relieve stress and anxiety.

Create a good sleep routine.

Try to create a comfortable and relaxing sleep routine. For example, every night before bed take a hot bath or read a few chapters of a good book. If you do this every night, it will signal to your body that it is time for sleep. The most important thing is that this routine works for you. Here are some tips to get you started:

Tips for creating relaxing sleep environment:

• Make sure your mattress, bedding, and pillows are comfortable for you.
• Pleasant smells, like lavender, may help you sleep. Try an aromatherapy mist on your pillow.
• Buy a fan or white noise machine to drown out other distracting noises.
• Turn out all the lights, and use blinds or curtains to cover the windows.
• Do not leave the TV or computer on while you are trying to fall asleep.
• Silence all call, email, and text alerts on your phone.

Tips for sleeping through the night:

• Try to go bed and wake up at the same time each day.
• Choose a small snack, not a large meal, before bed.
  • Digestion may wake you up, but a small snack will keep you from getting hungry during the night.
• Use the restroom right before going to bed.
• Exercise during the day, but do not exercise right before bed.
• The buildup of adrenaline and endorphins from exercise makes it difficult to wind down.
• Limit daytime naps to no more than 30 minutes.
• Avoid caffeine, alcohol, and tobacco products.

Talk to your healthcare team.

Always talk to your healthcare team if you are having insomnia or difficulty sleeping. Your doctor may recommend prescription medications or over-the-counter sleep aids to help you fall asleep and stay asleep. Do not take any medications without consulting your healthcare team first. Some sleep aids can be habit-forming so only take these medications as directed by your doctor.

Lactose intolerance occurs when the body cannot digest milk sugar (lactose). Some patients experience lactose intolerance, with symptoms like diarrhea, gas, and stomach cramps after having dairy. These tips may help to relieve symptoms.

• Avoid dairy products and foods containing lactose and instead choose lactose-free or reduced lactose milk products.
  • Most grocery stores sell lactose-free milk and ice cream.
  • Consider trying products made with soy or rice instead after checking with your healthcare team. Soy milk, rice milk, and almond milk are available at most grocery stores.
  • Yogurt with live active cultures and hard cheeses such as parmesan and aged cheddar are lower in lactose. You may find these to be better tolerated and less likely to cause symptoms
  • Avoid using butter, margarine, cream, or soft cheeses when cooking or preparing foods.
• Read labels carefully.
  • Avoid foods that have been prepared with milk, butter, milk solids, cream, casein, or whey.
  • Avoid products with ingredient lists that say “May contain milk”.
• Talk to your doctor about using over-the-counter enzymes.
  • Lactase enzyme products are available in capsule, liquid, or pill form.
  • Taking these enzymes with your meal may help you to digest the lactose in milk and prevent symptoms.
• Choose other calcium-fortified or high-calcium foods.
  • Read labels to find foods that have been fortified with calcium to ensure you are meeting your calcium needs.
  • There are many ways to meet your calcium needs from foods other than dairy products. Other good sources of calcium include leafy green vegetables, broccoli, fortified orange juice, fortified cereals, canned salmon, tofu, almonds soy beans, and white beans.
  • Talk with your physician or a registered dietitian about whether you could benefit from taking a calcium supplement.
• Symptoms of lactose intolerance may improve overtime after treatment ends, but sometimes it can be a long-term problem.

Loss of appetite interferes with good nutrition before, during, and after treatment and can contribute to dangerous weight loss. The following are some tips to optimize nutrition while dealing with appetite loss.

• Manage any other nutrition related side effects that may contribute to appetite loss.
  • Nausea, vomiting, diarrhea, constipation, dry mouth, sore mouth, swallowing difficulty, and heartburn may lead to loss of appetite.
  • Talk to a registered dietitian and your healthcare team for assistance with any of these side effects. It is important to get help managing any of these side effects to increase appetite.
• Take note of when your appetite is best.
  • For some people this is in the morning and appetite diminishes throughout the day. For other people it may be the opposite.
  • When you feel well, eat as much nutritious food as possible in case you do not feel well later.
  • Do not limit or restrict food intake when appetite is good.
• Eat 5-6 small meals per day and snack anytime.
  • Small amounts of food are typically easier to digest and are easier on the stomach. It is often easier to better meet nutrition needs while battling appetite loss with smaller amounts of food more frequently.
• Keep healthy snacks around, and do not go more than three hours without eating.
  • Pack a cooler or insulated lunch bag to take on longer trips or to appointments when the wait time is variable.
  • Keep small containers of fruit, dried fruit, trail mix, small bottles of juice, yogurt, cheese, whole grain crackers, cereal, granola bars, and other portable food items that are easy to eat and require little to no preparation.
  • Always keep snacks visible and available as a reminder that it is important to eat to get the body the nutrients it needs.
• If food is not appealing, have a nutritious beverage instead.
  • A high-protein shake or smoothie can have as many calories as a small meal or large snack.
  • Have a ready-to-drink liquid nutrition supplement when food is not appealing.
  • Milkshakes, smoothies, or protein shakes can be made with yogurt, milk, ice cream, protein powder, fruit, and other ingredients using a blender. Have these ingredients available for times when a drink sounds better than a meal.
• Drink liquids between meals.
  • Sometimes drinking liquids with meals causes the stomach to get full faster. This prevents eating enough and maximizing nutrition from food sources.
  • If an early feeling of fullness is a problem, try waiting to drink any liquids until after a meal and do not drink any liquids for at least 30 minutes before a meal.
• Add calories and protein to foods to give their nutrient content a boost.
  • There are ways to add protein and calories to foods that are already eaten regularly.
  • Add a scoop of protein powder to a shake or smoothie.
  • Add healthy fat such as olive oil, nuts, or nut butter to recipes and other dishes to boost the calorie content.
  • Ask a registered dietitian for other suggestions on how to increase the protein and calorie content of foods.
• Exercise or do some physical activity at least an hour before a meal.
  • Check with your healthcare team first before adding exercise to your routine.
  • Regular exercise may help increase appetite.
  • Go for a 20-minute walk before sitting down to a meal.
• Get in the habit of having a bedtime snack.
  • An easy-to-digest snack such as yogurt and fruit, cheese and crackers, or peanut butter and crackers is an easy way to get some additional nutrition and will not impact appetite for the next meal.
  • If reflux or heartburn is an issue, have this snack at least one hour before lying down.
• Emotions are often related to appetite. Talk to your healthcare team about managing your emotional well-being.
  • Depression, anxiety, fear, and stress can all affect appetite.
  • Trained health professionals such as social workers and psychologists can assist in managing these emotions.
  • Support groups are another resource that may help in processing these emotions.

Lymph nodes are part of your body's immune system. The immune system helps your body fight infection and disease by circulating lymph fluid throughout the body. Lymph nodes carry lymph fluid from node to node through this web-like system.

Cancer may affect the lymph nodes, making it necessary to remove those nodes. When lymph nodes are removed, it changes the flow of the lymph fluid.

Lymph fluid may build up in parts of the body where lymph nodes have been removed or damaged. This causes lymphedema, a swelling that can be very painful. It is important to learn if you are likely to suffer from lymphedema, as you can take steps to avoid or lessen its impact.

Who is at risk for lymphedema?

• Breast cancer patients whose surgery required removal of lymph nodes under the arm
• Other cancer patients whose treatment also required the removal of lymph nodes under the arm
• Cancer patients whose surgery required removal of lymph nodes in the neck (head and neck cancers, thyroid cancer)
• Cancer patients who have had lymph nodes removed from the groin area (testicular cancer)
• Cancer patients who had radiation treatment that damaged lymph nodes

What are the symptoms of lymphedema?

• Swelling (pressing the skin with your finger may leave a dent or impression)
• Pain
• Numbness
• Loss of ability to move the affected area
• Hardened skin
• Ulcerations/tears in swollen skin

How can I avoid lymphedema or avoid making my lymphedema worse?

• If you had lymph nodes removed from under your arm, do not have your blood pressure taken from that arm, especially if you have had the symptoms of lymphedema.
• Similarly, do not have blood drawn or receive shots or IVs in an area where lymph nodes have been removed.
• Avoid sunburns by staying out of the sun and always wearing at least SPF 30 sunscreen.
• Use insect repellent when outside to help avoid bites that could lead to infection.
• Avoid trauma or injury to the area where lymph nodes have been removed.
• Avoid heavy lifting with the affected arm.
• No tattoos on the affected arm.
• Do not wear tight clothing, bands, shoes, or jewelry on the affected area.
• Wear a compression sleeve or stocking if ordered by your doctor.
  • The snug way a compression sleeve or stocking fits on your arm or leg helps lymph fluid move though the system instead of getting blocked.
  • Compression sleeves for lymphedema need to fit correctly. An ill-fitting compression sleeve may make lymphedema worse.
  • Your healthcare team can help you find the correct compression sleeve for you.
  • Compression sleeves and stockings are often not covered by health insurance, including Medicare and Medicaid plans.
    • Ask your case manager or representative if lymphedema sleeves and treatments are covered by your plan.
    • Ask your healthcare team about free or reduced-cost resources in your area or at your treatment center.
    • Seek financial assistance.
      • CancerCare: (800) 813-HOPE (4673)
      • Patient Advocate Foundation: (800) 532-5274
• Keep your skin moisturized and healthy to avoid cracks that may lead to infection.
• Maintain a healthy body weight.
  • Eat a variety of fruits and vegetables.
  • Choose whole grains.
  • Choose lean proteins.
  • Limit sugar and sweets.
  • Drink eight glasses of water a day.
• Exercise.
  • Ask your healthcare team which exercises are right for you. Some exercises may make lymphedema worse.
  • Talk to your healthcare team before beginning any new exercise program.

How can I manage lymphedema?

• Tell your healthcare team as soon as you notice the symptoms of lymphedema.
• If your lymphedema is moderate to severe, you doctor may recommend you to a lymphedema therapist or a physical therapist for complex decongestive therapy (CDT).
  • Complex decongestive therapy involves a few different strategies, as follows:
    • Massage
    • Skin care
    • Special exercises
    • Compression bandages
  • The massage is called manual lymphatic drainage (MLD). This massage style helps move lymph fluid through the system to decrease pain and swelling.
  • Your lymphedema therapist may also recommend a pneumatic compression sleeve.
    • These sleeves have an attached pump that inflates and deflates the sleeve around the affected arm or leg.
    • The pump helps move lymph fluid through the system.
• Follow the same guidelines for avoiding lymphedema listed above.
• Lymphedema can make it easier to have infections in the affected area.
  • Tell your healthcare team immediately if you notice any of the signs of infection:
    • Fever
    • Redness or red streaks
    • Warmth or heat at the swelling area
    • Cloudy pus or drainage

Nausea and vomiting are common side effects of cancer treatment that can cause dehydration, poor nutrition, and weight loss. Follow these tips to control nausea and vomiting.

• Take anti-nausea medications as prescribed by your healthcare provider.
  • It is important to take anti-nausea medications as prescribed.
  • Do not wait until the onset of nausea to take medication.
  • It is best to attempt to keep nausea managed with medication to allow for consistent eating and optimal nutrition.
  • Call your healthcare provider if you are taking the medication as prescribed and it is not providing any relief. A different medication may be needed.
• Track nausea to determine causes and trends.
  • Some nausea may be directly related to chemotherapy.
  • It is beneficial to know how soon after chemotherapy the nausea begins. Sometimes it is immediate and other times the onset is delayed.
  • Tracking may help to identify other triggers or causes of nausea.
• Keep odors to a minimum.
  • Odors can lead to nausea so it is best to choose foods with little or no odor such as oatmeal, cereals, canned fruit, shakes, and smoothies.
  • When preparing food at home, opt for foods with short cooking times and minimal odor such as pancakes, scrambled eggs, reheated soup, or other prepared foods that just require reheating.
  • Cool and room temperature foods usually have fewer odors than hot food.
  • Avoid cooking foods that have long cooking times such as casseroles, meats, and slow cooked meals.
  • Ask friends or family members to cook these items in an alternative location like a neighbor's kitchen.
• Eat several small meals or snacks during the day.
  • Eating small meals or snacks 5-6 times per day instead of 2 or 3 larger meals may help with nausea management. This keeps the stomach from getting too empty and prevents excess stomach acid.
  • Chew all foods very well. The digestion process begins in the mouth.
  • Keep bland, odorless snacks on hand for easy meals and snacking. Some examples are crackers, cheese, canned fruit, yogurt, toast, rice, and pasta.
  • Not all foods are appealing to everyone. The key is to find the foods that are tolerable and stock up on those.
• Create a relaxing environment for eating and snacking.
  • Lighting, temperature, and other external cues may make nausea worse.
  • Dim lighting and cooler temperatures tend to be better for nausea management.
  • The use of a fan or ceiling fan may also make a difference.
  • It is important to be removed from situations that contribute to anxiety when attempting to enjoy a meal or a snack. (i.e. loud voices, arguing, loud music, or non-relaxing television programs).
  • Soft relaxing music, a relaxing television program or another activity that is relaxing in a cool, dim room may be the best environment for meals and snacks.
  • Rest after meals but do not lie flat as this may trigger nausea.
• Experiment with different foods.
  • Everyone is an individual and not all foods work for everyone when nausea is an issue. Try to be patient and experiment with different foods.
  • Start with bland foods with minimal odor and introduce them one at a time.
• Avoid foods and behaviors that tend to trigger nausea.
  • Some foods are triggers for nausea for unexplained reasons. Some of these reasons may be psychological. It is best to avoid these foods for optimal nutrition. The time that it takes to recover from an episode is time that the body is missing out on good nutrition.
  • Foods that are harder to digest and stay in the stomach longer can be triggers for nausea. These foods are usually higher fat foods such as fried foods and foods prepared with a lot of butter or oil.
  • Spicy foods are usually not tolerated well.
  • Some behaviors such as eating in a restaurant may trigger nausea. If this is the case, order food to carry out and eat it in a more relaxing environment.
  • Caffeine and smoking contribute to nausea.
  • Limit or avoid smoking, and drink only decaffeinated beverages.
• Try foods and drinks containing ginger.
  • Ginger is a spice that has shown some promise for relief from nausea.
  • Ginger snaps, ginger ale, ginger gum, or ginger tea may be options that can help manage nausea.
  • Ginger is also common in some Asian recipes.
  • Ginger supplements are available; however, they have not been studied extensively to determine an effective dose.
• Avoid drinking while eating.
  • Sometimes excess liquid in the stomach contributes to nausea.
  • It is best to drink any beverages at times other than meal times.
  • The best beverages to choose are water, 100% fruit juices without added sugar, and caffeine-free soda that no longer has carbonation.
  • Ginger ale specifically may help with nausea.
• Wear loose-fitting, comfortable clothing.
  • Clothing that is tight especially around the midsection can trigger nausea.
  • Soft, comfortable fabrics tend to be more relaxing as well.
• Stay hydrated if vomiting occurs.
  • Continue to drink clear liquids including water and other electrolyte containing beverages like sports drinks.
  • Attempt to eat bland foods such as crackers or toast.
  • If vomiting is continuous and cannot be controlled, contact your healthcare provider immediately.

Pain related to cancer comes in many different forms. Pain can be caused by the cancer itself, or it can be a side effect of treatment.

For the best pain management, you and your healthcare team will first need to find out the cause of your pain. Be prepared to answer these questions:

• How severe is your pain?
• Is there anything that makes it better?
• Is there anything that makes it worse?
• What does it feel like—an ache or a sharp pain, dull, throbbing, or tingling?
• Is the pain in only one part of your body?
• How does the pain interfere with your daily life?

Is the pain a side effect of treatment?

Chemotherapy, radiation, and surgery are the three most common cancer treatments, and pain is a potential side effect for all three. However, the type of pain caused by each is different.

Chemotherapy can cause the following types of pain: muscle and joint aches, mouth sores, headaches, and neuropathy. Neuropathy is an unpleasant tingling or numbness, usually in the hands or feet. Damage to nerve endings causes this feeling.

Radiation causes the skin at the treatment site to become dry, red, and painful like a mild to moderate sunburn. Sometimes these burns blister. Depending on the location of radiation, there may be other side effects. For example, radiation to the brain may cause headaches.

Surgery causes pain at the incision site. Depending on the extent and location of the surgery, this pain could be mild to severe. Surgery can damage muscles and tissues leading to range of motion problems. Surgery can also damage nerves and cause neuropathy. Amputations and mastectomies can lead to “phantom” pains where the removed limb or breast used to be.

Is the pain a side effect of the cancer itself?

Depending on size and location of the tumor, pain could be from the cancer itself. If the tumor is pressing on nerves, joints, or bones, it can cause pain. This type of pain is more common with advanced or metastatic cancer, especially when the cancer spreads to the bones. Tumors in the bones can cause fractures as the tumors continue to grow.

Pain Management Plans

Your healthcare team can help create the best pain management plan for you. If the first plan you try does not work, tell your healthcare team. You may need to try a different plan. Open and honest communication with your healthcare team is very important. Pain is a difficult side effect to treat. It may take a few tries to find the best plan for you. Do not be afraid to seek a second opinion if needed.

Your pain management plan may include:

Pain Medications
Your doctor may prescribe pain medications or suggest over-the-counter pain medications. Ask your doctor before taking any over-the-counter medications. Some pain medications can cause nausea or constipation. Your doctor may be able to suggest additional medications to help with these side effects. You may have to try a few different types of medications or dosages to find what works for you.

Physical Therapy
Physical therapy uses exercises to help improve strength and motion. If your pain is related to loss of range of motion or difficulty doing physical activities such as walking, physical therapy may help ease pain.

Exercise
Regular exercise, even something as simple as a daily walk, may also help with pain. Exercising is good for the body. It can also make you feel better mentally too. Exercising releases endorphins, natural chemicals that make you feel happier. Exercising also combats fatigue which is a common side effect along with pain. Always ask your doctor before beginning an exercise plan.

Complementary and Alternative Medicine
Some cancer patients find success at relieving pain with complementary and alternative medicine (CAM) such as acupuncture, guided imagery, massage, supplements and vitamins, or yoga. The phrase “complementary and alternative medicine” means treatments outside the standard scope of what you would find at a hospital or treatment center. Complementary medicine is used along with standard treatment. Alternative medicine is used instead of standard treatment.

Always discuss the pros and cons of each treatment you consider with your healthcare team. If you are considering a complementary treatment, inform your medical team BEFORE you are treated to make sure it will not negatively interact with your standard treatment. If you are considering quitting standard treatment for an alternative treatment, remember: standard treatments go through a long and careful research process to ensure that they are safe and effective, but less is known about most types of CAM.

For more information on CAM, visit the National Center for Complementary and Alternative Medicine website.

Palliative Care
Palliative care provides relief from pain and other symptoms, but it does not provide a cure. For cancer patients, common palliative therapies include surgery, radiation, or chemotherapy as a method of shrinking tumors that are causing pain. Palliative care is most commonly used for advanced or metastatic cancers.

Emotional Support
Taking care of your emotional well-being can also help manage pain. There are a number of ways to find emotional support—peer partnering programs, support groups, and one-on-one counseling.

Your doctor may even prescribe antidepressants, which have been shown to help with nerve pain as well as emotional well-being.

Managing Other Side Effects
Other side effects of treatment, such as fatigue, nausea, or loss of appetite, may be making your pain worse. You may be able to manage many of these side effects with simple nutrition and habit changes.

Heartburn, reflux, and GERD (gastroesophageal reflux disease) may occur during cancer treatment. Cancer treatments or medications may affect parts of your digestive tract and cause the food and liquids in your stomach to reflux (travel back) into your esophagus (food pipe). If you have reflux, you may have symptoms such as swallowing difficulty, a sore throat, sour taste in your mouth, heartburn and painful digestion.

Talk with your healthcare team for the best care for reflux. Here are some tips and guidelines to help control reflux:

Go small.

• Eat 5-6 small meals or snacks throughout the day. Smaller amounts of food are easier for the body to digest and absorb.
• Smaller amounts of food also mean there is less food that can travel back up the food pipe.

Choose lean.

• Avoid fried and fatty foods. These foods are hard to digest and stay in your stomach for a long time. Time increases risk for reflux.
• Choose baked, broiled, or grilled foods instead.

Dress for comfort.

• Wear loose-fitting clothes, especially clothes that are not tight around your stomach.
• Clothes that are tight around the stomach can trigger reflux.

Avoid smoking and alcohol.

• Smoking cigarettes (including e-cigarettes) and drinking alcohol can trigger reflux.
• Instead of after-dinner drinks and cigarettes, chew sugarless non-mint gum for 30 minutes after meals. This encourages food to move through your digestive system.

Sit up.

• Pay attention to your posture.
• Sit up at least 1 hour after eating.
• Good posture helps your breathing and may reduce fatigue during eating.
• Raise the head of your bed 6 to 9 inches by putting wooden blocks under the legs of the head of your bed.

Slow down.

• Eat slowly and chew food really well. Digestion begins in the mouth.
• Smaller food pieces are much easier to digest and are less likely to cause discomfort.
• Meals eaten in calm, relaxed place seems to be better digested.
• Added stress from treatment can also trigger reflux; try to eat when you are feeling most relaxed.

Choose well.

• Some specific foods and drinks may cause reflux symptoms.
• Some common problem foods and drinks may be: chocolate, cocoa, mint, whole milk, caffeine, pepper, some fruits/juices, pastries and other high-fat desserts.

Write it down.

• Record in a log the times you eat, the foods and drinks you consume, and any reflux symptoms.
• If you eat a large portion of a problem food, you may have symptoms. Try a small portion and take notes in your log. Use your log to eliminate items that cause reflux symptoms.
• Avoid “problem foods” for a couple of days to see if symptoms disappear.

Avoid eating before bed.

• Avoid eating too close to bedtime.
• Have your last food or drink 1-3 hours before you recline.
• If still having trouble sleeping due to reflux, you may need to raise the head of the bed so that gravity helps keep food down in the stomach.

Ask for help.

• Consult a local registered dietitian for specific recommendations based on your level of food tolerance.
• Talk to your healthcare team if symptoms persist or get worse.

Some cancer treatments can cause mouth sores, ulcers, and tender gums, leading to dehydration, poor eating, and weight loss. Follow these tips to manage sore throat, mouth, and tongue.

• Choose soft, bland foods.
  • Softer foods will be easier to chew and swallow.
  • Soups and stews are good options, as long as meats are soft and tender.
  • Try breakfast foods like instant oatmeal, grits, pancakes, waffles, and cold cereal that has been softened in milk.
  • Pick side dishes like cottage or ricotta cheese, macaroni and cheese, mashed white or sweet potatoes, and rice or risotto.
  • Try desserts like custard, tapioca pudding, ice cream, milkshakes, and sherbet.
  • Choose snacks like applesauce, gelatin, smoothies, and yogurt.
• Prepare foods in ways that make them easier to eat.
  • Cut foods into small pieces. You may consider using a blender or food processor to puree foods.
  • Cook foods until they are soft and tender.
  • Serve foods with gravy, broths, or sauces.
  • Choose soft or canned fruits or applesauce instead of raw fruits with tough skins.
• Avoid foods and drinks that make mouth sores worse.
  • Avoid citrus fruits and juices, salty or spicy foods, and acidic foods like tomatoes.
  • Do not drink carbonated or caffeinated drinks.
  • Refrain from having beer, wine, liquor, or any other type of alcohol.
• Avoid very hot foods.
  • Hot foods can cause mouth and throat discomfort.
  • Choose room temperature or cold foods that are soothing.
  • Allow soups and hot foods to cool to room temperature before serving.
  • Try freezing fruits, and suck on frozen fruit pops, fruit ices, or ice chips.
• Choose foods that are good sources of protein to combat weight loss.
  • Aim to have a good source of protein with meals and snacks.
  • Ground meats, eggs, cottage cheese, yogurt, custard, beans, lentils, and smoothies are good soft food choices that also provide protein.
  • Eat small, frequent meals. You may find it easier to eat smaller amounts at a time.
• Drink at least 8-10 eight-ounce glasses of water each day.
  • Drink liquids with your meals as this will make it easier to swallow foods.
  • Sip cool drinks in between your meals.
  • Drink with a straw. This can help push the foods past the painful sores in your mouth.
  • Avoid caffeinated or/and carbonated beverages.
  • Avoid alcohol. Alcohol can irritate the mouth.
• Use good mouth care.
  • Rinse your mouth several times a day. Mix ¼ tsp. of baking soda and 1/8 tsp. salt with 1 cup warm water to make a rinse that removes food and promotes healing.
  • Do not use a mouthwash that has alcohol. Alcohol makes a sore mouth worse.
  • Use a toothbrush with soft bristles.
  • Remove dentures (except during eating) if your gums are sore. Keep dentures clean.
  • Avoid cigarettes, cigars, and tobacco products.
  • Ask your doctor about special mouthwashes and sprays that can numb the mouth and throat.
  • Tell your doctor if your gums are bleeding or if you have white patches in your mouth. Both can be signs of infection.

Weight gain is common among cancer patients. This can be for a variety of reasons. The following tips help maintain a healthy weight before, during, and after cancer treatment.

• Know the factors that can cause weight gain.
  • Medication, hormone therapy, or chemotherapy can lead to weight gain.
  • Fatigue and other side effects can cause decreased physical activity.
  • Stress, fear, or depression can lead to changes in eating habits.
  • Fluid retention causes swelling.
  • Eat a variety of fruits, vegetables, whole grains, and beans. o All of these foods are high in fiber and low in calories. o Fiber helps you feel fuller longer.
• Choose whole grain foods.
  • Whole grains also contain fiber and are a lasting energy source.
  • Whole grain foods include whole grain breads, cereals, pasta, crackers, and brown rice.
• Choose lean proteins.
  • Protein foods also help you feel fuller longer.
  • Lean proteins include eggs, fish, skinless chicken, turkey, lean beef, lean pork, beans, and soy products.
• Choose low-fat or fat-free dairy products.
  • Low-fat and fat-free dairy products contain the same amount of protein as regular dairy products.
  • Low-fat and fat-free dairy products include 1% or skim milk, low-fat yogurt and reduced-fat cheese and cottage cheese.
• Limit foods high in fat and calories.
  • High-fat foods like regular butter, creamy dressing and sauces, sour cream, mayonnaise, fried foods, and dessert contain more calories and can contribute to weight gain.
  • Limit frequency and portions of high-fat foods and choose reduced-fat items when possible.
  • Avoid high-fat cooking methods, such as pan or deep frying. Broiling, steaming, grilling, and roasting are recommended.
• Avoid high-calorie beverages.
  • Avoid drinking large amounts of sugar-sweetened beverages such as sodas, sports drinks, sweetened teas, lemonade, and sweetened fruit juice.
  • Choose low-calorie, low-sugar beverage options such as water and unsweetened tea.
  • Limit or reduce alcohol consumption. If alcohol is consumed at all, it is best to limit to no more than one drink per day for women and two drinks for men.
• Avoid eating when you are not physically hungry.
  • Listen to your body. Don't confuse boredom or stress for hunger.
  • Try making a list of alternate activities you can do when you have the urge to eat when not hungry.
• Watch your portion sizes.
  • Try measuring out your portions so you know exactly how much you are eating.
  • Check the nutrition label to determine serving sizes.
  • Choose to eat all meals and snacks off of a plate rather than out of the package so you can keep track of how much you are eating.
• Limit eating out.
  • Restaurants often serve large portions of higher calorie and higher fat foods.
  • Limit eating out so you are not tempted with large portions of these foods as often.
• Write down your intake.
  • Studies show that those who record all of their food and drink intake eat less calories than those who do not.
  • Keeping a food journal could help keep you mindful about appropriate portion sizes and urges to eat when not hungry.
• Try exercise.
  • Aim for 30 minutes of exercise every day if able.
  • Always discuss any changes in exercise with your physician.
• Always discuss weight gain with your physician.
  • A physician can help determine the cause of weight gain and can give recommendations for how to appropriately manage weight gain.
  • Do not go on a diet to lose weight without discussing with your physician first.

During cancer treatment, the body needs more calories and protein, especially when side effects can make it difficult to eat. Follow these tips to increase intake.

• Eat small, frequent meals (5-6 a day) instead of 3 large meals.
  • Eat every 2 to 3 hours even if you do not feel hungry.
  • Set a timer to remind you it is time to eat. Eat the most when you feel hungriest.
  • Eat protein foods like chicken, fish, meat, eggs, nuts, and beans first.
• Use smoothies and shakes to get in calories and protein.
  • Liquids can be easier to consume than solid foods.
  • Smoothies or shakes can serve as a small meal replacement.
  • Add ingredients such as whole milk, powdered milk, protein powder, peanut butter, ice cream, or yogurt to smoothies or shakes to add calories and protein.
  • Premade liquid nutrition supplements are available at grocery and drug stores. Ask a registered dietitian which type is best for you.
  • Ingredients such as whole milk, peanut butter, ice cream, yogurt, or fruit can be added to liquid nutrition supplements.
• Add more fats to foods to increase the calories.
  • Fat has more calories per gram than carbohydrates or protein.
  • Use butter, oils, mayonnaise, sour cream, and salad dressings liberally.
  • When cooking, use oil or butter instead of a nonstick spray.
  • Add mayonnaise to sandwiches and tuna or chicken salad.
  • Add peanut butter or cream cheese to toast or crackers.
• Drink most liquids between meals instead of with meals.
  • Liquids such as water, juice, or soda while you eat can make you feel full faster.
  • Drink only small amounts with meals.
  • Drink higher calorie liquids like juice and milk between meals.
  • Drink smoothies, shakes, and nutrition supplements with or in place of a meal.
• Snack regularly throughout the day.
  • Keep quick and easy snacks with you.
  • Try granola bars, trail mix, peanut butter crackers, nuts, and dried fruit.
  • Keep your favorite snacks around so you will eat more.
  • Eat a bedtime snack. It will not affect your appetite at your next meal.
  • Peanut butter crackers, half a sandwich, yogurt, and cereal are good bedtime snacks.

Each type of cancer treatment—chemotherapy, radiation, surgery, and hormonal therapy—can cause possible sexual side effects. Side effects may vary depending on the type of cancer, the specific mode of treatment, and the individual's response to treatment. Talk to your healthcare team about what you should expect from treatment.

Lack of Desire

During and after cancer treatment, many women report a lack of sexual desire. Lack of desire may come from hormonal changes such as early menopause or other side effects, making sex unenjoyable.

• Rethink what sex and intimacy mean.
  • Do not expect sex after cancer to be exactly the same as sex before cancer. Your body has been through a lot of changes.
  • Be patient. It may take some time to discover what is comfortable and pleasurable for you.
• Ask your doctor about estrogen therapies to increase estrogen and if they are safe for you to use.
  • Low levels of estrogen can cause female sexual dysfunction.
  • Estrogen therapies can help with lack of desire and dryness.
  • Estrogen therapies come in pills, creams, patches, and vaginal rings.
  • If your cancer is hormone driven, estrogen therapy may not be safe for you.
• If you are taking anti-depressants or pain medication, talk to your doctor about adjusting your dosage.
  • Both these medications can cause lack of desire.
• Manage other side effects such as dryness, pain, nausea, or fatigue that may be causing your lack of desire.

Dryness

Early menopause, triggered by chemotherapy, adjuvant therapies, or surgery, can cause vaginal dryness. Radiation to the pelvic region can also cause dryness.

• Use a water-based lubricant during sex.
  • Stay away from scented and warming lubricants. These can irritate the vagina, actually making dryness worse.
  • Do not use petroleum jelly based lubricants.
• Try vaginal moisturizers to improve overall dryness.
  • Vaginal moisturizers are different from lubricants. You do not use them only during sex. If used regularly, they improve overall dryness and vaginal health.
• As mentioned above, ask your doctor about estrogen therapies and if they are safe for you to use.

Pain

Pain during intercourse may occur for a few reasons such as dryness or scar tissue. Radiation to the pelvic region may cause minor burns as well as scarring that causes the vaginal canal to shrink. Gynecological surgery can damage or result in the removal of sex organs.

• After surgery, ask your doctor if and when it is safe to have sex.
• If the shape of the vagina has changed from treatment, you may need to adjust the way you have sex by trying new positions or new activities.
• After gynecological surgeries that affect the vagina, reconstructive surgery may be an option.
• A vaginal dilator can be used to stretch the vaginal canal. Vaginal dilators are smooth plastic cylinders of different widths. By beginning with the smaller ones and inserting them into the vaginal canal regularly, the vagina begins to stretch, making intercourse less painful. Vaginal dilators also make medical pelvic exams more comfortable.
• Pain may come from dryness. If you are also experiencing dryness, try the tips above.

General pain in other parts of the body can also make sex uncomfortable and decrease your desire to be intimate.

Difficulty Reaching Climax or Orgasm

Surgery and other treatments that directly affect the pelvic region can result in loss of sensation if nerves are damaged. This can make achieving an orgasm difficult for some women. Actions that worked before treatment may no longer feel the same.

• Work on managing all of side effects that may be affecting your sex life.
• For most women, vaginal penetration does not provide enough stimulation for orgasm. Extended clitoral stimulation may be needed.
• Use your mind. Make sure you are comfortable and in the right mindset for sexual activity. Try imaging sexual fantasies to get in the mood.
• Try using a vibrator to increase stimulation. Vibrators can be purchased at a drug store or discreetly online.

How you feel about yourself can affect your sex life. Cancer and cancer treatment can cause significant changes to your body. You may have hair loss, weight loss, weight gain, or scars. With these changes, you may not feel the same way about your body. This is all normal. Do not be critical of yourself. Your body battled cancer.

Below are tips for managing issues related to self-esteem and body image.

Hair Loss

• Hair usually grows back after treatment ends.
• In the meantime, try wigs, hats, and scarves.
• When your hair does begin to grow back, use a gentle shampoo such as baby shampoo.

Weight Changes

• Talk to your healthcare team about reaching and maintaining a healthy weight.
• Ask your healthcare team if it is safe for you to start an exercise program.
  • The endorphins released during exercise can also make you feel better emotionally.

Surgical Scars

• Most surgeries leave some scars. Try using over-the-counter lotions and gels to help minimize incision scars. Moisturizers made with cocoa butter also minimize scars.
• After surgery for breast cancer, some women choose to wear a breast prosthesis.
  • Insurance companies often cover a prosthesis.
• After surgery for breast cancer, some women choose to have breast reconstructions surgery.
  • Talk to your healthcare team about your options.

Emotional Support

You have to care for your mental health as well as your physical health. If you are struggling with anxiety or sadness, you probably don't feel like having sex. Some options for emotional support include: peer partnering programs, support groups, and one-on-one counseling.

Being able to talk openly with your partner about sex is very important. What worked for you both before cancer may not work now. You may need to try different things to find what works for you both. If it has been a while since you've been intimate, start slowly with simple kissing and touching. Here are some basic guidelines for talking to your partner:

• Be honest.
• Always tell your partner if something hurts or is uncomfortable.
• If something feels good, let your partner know.
• Be patient with yourself and your partner.
• Set the scene by going on a romantic date or watching a movie together at home.

Your healthcare team is made up of health professionals. You should feel comfortable telling them anything. There is nothing embarrassing about sexual dysfunction, as it can happen following cancer and its treatment. After fighting cancer, you deserve to have a healthy sex life.

You may wish to talk to healthcare professionals who specialize in areas related to sexual dysfunction including:

• Gynecologist
• Endocrinologist
• Sex therapist
• Psychologist or counselor

Talking about sexual dysfunction can be difficult. Here are some sample questions to begin your conversation with your doctor:

• How will treatment affect my sex life?
• What can I do to manage sexual side effects?
• I have pain and dryness during sex. What can I do to manage this?
• I no longer feel any desire to have sex. What can I do to feel like myself again?
• Could you recommend a specialist?
• Will treatment affect my fertility?

Cancer treatments can lead to infertility or make it difficult to have children. Gynecological surgery can cause infertility. Chemotherapy and adjuvant therapies can trigger early menopause in women. Even though this process sometimes reverses in young women, it can still make conceiving difficult. Chemotherapy can also damage reproductive organs. Radiation to the pelvic area can damage reproductive organs.

Women do have options to preserve their fertility. However, it is important to talk to your healthcare team about fertility and your options before you begin treatment. Many fertility- preserving options must be done before the damage caused by treatment occurs.

Before beginning treatment, some women freeze and bank eggs or embryos (fertilized eggs). Fertility preservation can be a long process so you will need to factor this into your timeframe for treatment. Some fertility treatments require that you take hormones before the procedure. For women with certain types of cancer, taking these hormones is not safe.

Some steps can be taken to protect reproductive organs during treatment. For example, during radiation treatment, depending on the area receiving radiation, you may be able to use a shield.

If you continue to have sex during treatment, be sure to use proper protection. Pregnancy during chemotherapy or radiation is not safe for the mother or the child. Even if your periods stop during treatment, you may still be able to conceive so always use a form of birth control. Some cancers may affect your ability to use hormonal birth control methods, such as oral medication and devices such as IUDs and hormone rings. Make sure you ask your doctor before resuming any birth control you used before your diagnosis. Since cancer treatment can compromise your immune system, be sure to always use condoms to protect against sexually transmitted diseases (STDs).

Talk to your healthcare team as soon as possible about your fertility status and options. For more information, visit Fertile Hope.