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CancerLynx - we prowl the net
August 6, 2012

Talking To Your Medical Team
Robert Wascher, MD, FACS, Ernest Rosenbaum, MD, Alexandra Andrews, Charles M. Dollbaum, MD, PhD, Karen Ritchie, MD, Sarah Schorr, RN, BSN, Francine Manuel, RPT, Jean Chan, BA, MA, SEd, Richard Shapiro, MD

Talking To Your Medical Team
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The effects of cancer and its treatment endure long after medical treatment ends. Some changes may actually be positive (i.e., you may have a better appreciation of life, or you may have become closer to your family and friends). Other negative changes (e.g., lingering pain, neuropathy, fatigue, scars, lymphedema, cataracts, etc) may serve as constant reminders that you have been diagnosed with cancer. When fatigue, neuropathy, painful or uncomfortable symptoms persist, you may sometimes have interactions with others that appear to be lacking in sufficient compassion and empathy. Friends and family, and even health care personnel, may appear judgmental or skeptical regarding your concerns, because fatigue, neuropathy, and/or pain are not always visible and can't be easily measured.

There are neuropathic changes associated with surgery, chemotherapy, radiation therapy, bisphosphonate therapy and hormonal therapy. Chemotherapy drugs commonly associated with peripheral neuropathy include vincristine, viblastine, vinorelbine, cisplatin, paclitaxel, docitaxel, carboplatin, oxaliplatin, cisplatin, etoposide, tenoposide, thalidomide, bortezomib and interferon. Any breast-associated surgery (e.g., mastectomy, lumpectomy, lymph node biopsy, breast implant placement, and breast augmentation or other types of breast reconstruction) may result in complications. Scar tissue that forms after surgery is not as elastic as healthy skin, and may entrap nerve fibers as the incision heals. Any healing complications such as an infection may further increase risks. Abnormalities in the healing of divided sensory nerve fibers (e.g., neuromas) may also lead to chronic pain in or near incisions.

It is normal to have tightness around the incision (and under your arm if you have had lymph nodes removed from the armpit region) during the first few months after surgery. Moreover, sensory nerves are often intentionally cut during surgery to remove the lymph nodes. This generally results in a tingling pins and needles sensation in the upper inner arm area during the first few weeks after surgery, as the brain attempts to compensate for the loss of innervation of this area. Later, numbness of the affected area usually ensues, and for the vast majority of patients, is not unsettling or uncomfortable. Severe burning or stabbing pain, or severe itching, near incisions, or in the upper inner arm, months after surgery is unusual, however, and may indicate the development of chronic pain. If pain interrupts your sleep at night or significantly impairs your daily life, or if wearing clothing is uncomfortable, then you should ask your physician to refer you to a physical therapist and/or a pain management specialist.

Suggestions for Discussing Symptoms With Your Medical Team
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1. Keep a daily symptom diary and make three copies; one for yourself, one for your doctor/caregiver to share your symptoms with, and one to be placed in your medical records.
2. Examples of noteworthy observations:

A) Time of pain or other symptom occurrence
B) Type of pain (i.e. stabbing, burning)
C) Pain duration whether chronic or sporadic
D) What triggers the pain?
E) Location of the pain
F) What helps to relieve the pain?

3. Address your needs for symptom management. Make sure that all of the members of your healthcare team are communicating with each other about your pain problem, and that a plan of action is established. If your physician dismisses your complaints with statements such as, "It's just phantom pain", or, "You're just anxious", etc., you may consider discussing your problems with your oncology nurse, other medical support staff or seek a second opinion from a specialist.

Most importantly, remember fatigue, neuropathy or pain do not necessarily mean recurrence of your cancer!!!

Suggestions For Alleviating Pain
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1. Medications: Your healthcare provider may prescribe medications in an effort to reduce or the severity or frequency of your symptoms, including nonsteroidal anti-inflammatory agents (NSAIDs) such as ibuprofen or naproxen, low-dose antidepressants (and SSRI medications in particular), and in rare and severe cases, narcotic pain relievers.

2. Physical Therapy: Early restoration of range of motion in the shoulder and arm is important to prevent a frozen shoulder syndrome, or to treat symptomatic muscle weakness associated with inadvertent injury to the nerves controlling shoulder muscles. These entities can cause pain separate from the neurogenic syndromes that can result from axillary lymph node dissections. Early restoration of upper extremity and shoulder mobility, and use of the arm, will also help reduce the severity of lymphedema.

3. Pain Management Specialists: A referral to a pain management specialist who is certified by The American Board of Anesthesiology-Added Pain Qualification or The American Board of Pain Medicine should be made in patients who do not rapidly respond to the measures already outlined.

4. Supportive Care Approaches may be useful, including guided imagery training, biofeedback, acupuncture, massage therapy, meditation, breathing, exercise (e.g., swimming, stretching), hypnosis, nutritional therapy, topical salves (e.g., calendula, capsaicin, and mentholated creams), placing a small pillow between you and the seatbelt, and wearing loose-fitting clothing constructed from soft, natural fibers.

Remember to proactively consult with your physician or other primary healthcare provider when considering the above interventions!

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