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Guidance on the use of medicinal marijuana
Dr Coward works closely with Dr Janet Schloss a Clinical Nutritionist and Naturopath who has over 19 years experience in private practice. Janet works part time seeing patients and part time conducting research. She completed her PhD at The University of Queensland and continues to conduct research to help patients and practitioners to establish evidence based practice.
Janet integrates with a number of Oncologists as the Nutritionist for their cancer patients. Janet has long been involved in research about cancer and nutrition particularly for individuals going through conventional treatment such as chemotherapy, radiation, surgery, immunotherapy and hormone treatment. She has also worked extensively with clients during and after their cancer/auto-immune treatment to help with means of reducing the likelihood of metastasis, tumour growth and inflammation as well as building good health, weight management, immune modulation and well being.
Below are some articles relating to frequently asked about nutritional options:
Palliative care “…is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” World Health Organisation, 2003.
First of all, a common phrase you’ll hear from Dr Coward is “Treat the treatable”, and he has a myriad of options at his disposal. Treating your cancer and maintaining quality of life is paramount.
Palliative care is not giving up.
So let’s debunk one of the biggest myths right now that having the palliative care team involved means a death within days.
Palliative care is a term that is greatly misunderstood, and there are many negative and distressing perceptions and feelings attached to it. The team are often referred to as the supportive care team, or the pain control team – because quite simply that is what they do and are experts in. Palliative care provides additional specialised supportive care to enhance quality of life.
We have found that, when appropriate, introducing patients and their families to palliative care services earlier helps to: remove the stigma attached; provide an opportunity for relationships to be developed establishing familiarity with the services and practitioners; care is optimised with symptom management such as pain control; support within the community is greater with specialised services that may allow symptom management outside of the hospital setting; and when end of life care is required this supportive team is already involved in your care and know of, respect and are able, to the best of their ability, carry out your wishes.
The presence of the palliative care team may vary throughout the course of your illness. At some stages they may be heavily involved by assisting to find the best course of treatment to manage your symptoms, other times they will be in the background, available as you require in the community or in hospital. Some patients have been known to palliative care services for years, some months and some only days. Whichever it may be, their support and expertise is invaluable.
More Myths exposed by Palliative Care Australia.
End of Life Services
Last Journey– Support to carers and families before and after loss by providing direction and guidance on the big and little things required at a time of grief.
Continuing to exercise throughout your treatment can be the vital key to how well you tolerate, cope and recover. Your level of exercise is unlikely to be at the same level of performance prior to your disease and interventions, however by persisting (within any limitations – for example post surgery restrictions) the benefits will be invaluable, you will maintain your cardiovascular health, muscle tone, improve your stress levels and consequently your emotional and mental wellbeing and improve your recovery. Often guidance is beneficial to instil confidence in what is appropriate throughout the different stages, we work closely with Physiotherapist Julie Allen.
Julie has a career of over 20 years experience with sports, injury rehabilitation, chronic back and neck pain and cancer rehabilitation. Graduating with first class honours from the University of Queensland, is a member of the Australian Physiotherapy Association and is endorsed by the Australian Health Practitioner Regulation Authority (AHPRA). As a fellow cancer survivor she is the passionate founder of The Pentimento Project.
“Physiotherapy has a supportive role to play in all aspects of cancer treatment. It can specifically target problems and symptoms that may or may not be related to your cancer regime. Prior to treatment, physiotherapy is useful to improve your health optimally prior to prolonged or intensive treatment. Throughout the course of your treatment, we aim to help you maintain normal function and wellness, minimise the impact of side effects and hence maintain a desirable quality of life. After your treatment is completed, the focus shifts to recovery, diminishing the late effects of treatments and if necessary guidance and support for a return to work program. Throughout this entire process our focus remains on empowering you to reach your goals, minimise the impact of treatment on life and assist you to move beyond cancer.”
Despite the current restrictive environment, The Pentimento Project can help to keep you healthy and active at home and continue to move you forward beyond your cancer experience. With the use of videos, educational material, in person consultation and now the option to have an in home Physiotherapy assessment and consultation via Telehealth link: help for you to regain or maintain your physical abilities is only an email or a phone call away. Email: hello@thepentimentoproject.com or call 0418 723 977.
Julie Allen, Physiotherapist and Founder – The Pentimento Project
Physiotherapy & Cancer Survivorship
Exercise is Medicine for Cancer Patients
Exercise is medicine for cancer patients. People with cancer who do the right exercise, at the right time, experience less side effects from their treatment, are less likely to have their cancer recur, improve their immunity and mental health and save money on health costs.
However, many people undertaking or recovering from treatment are understandably worried about what sort of exercise they can safely participate in. When you’re feeling unwell, or have not exercised in a long time, the thought of exercise can be confronting and intimidating.
Exercise should not be scary. You don’t need to join your local gym and lift huge weights or run 5km. You can receive the benefits from exercise from just a few easy exercises that can be done in your living room or just by walking up a hill or up the stairs. It really is that easy and it should be individually programmed to suit YOU and your needs. Exercise needs to be tailored individually and can be done either at home, in a safe gym environment or with the support of a group.
The Clinical Oncology Society of Australia (COSA) recommends all patients be prescribed exercise as part of their care. Just 150 minutes of moderate to vigorous exercise and 2-3 strength sessions a week can deliver real benefits for cancer patients.
Best of all, doing the right exercise is also affordable. Your GP can create an Enhanced Primary Care Plan for you, which covers most of the cost for up to five consultations with an exercise physiologist each year. In addition, exercise physiology rebates are available through all major private health funds. Exercise can be performed at home, you can start by simply going for a walk and doing the talking test – if you struggle to hold a conversation, you are working vigorously. If you can only say a sentence in a row you are working moderately.
Coward Oncology works closely with Valere Health to ensure our patients have access to the best quality exercise advice and guidance. Valere Health is owned by Morgan Farley, one of Brisbane’s leading experts in exercise oncology. Valere Health is one of the only exercise physiology providers solely focused on cancer patients. Morgan is also undertaking her post-doctorate in exercise and cancer at the University of Queensland.
Valere Health has one-on-one, small group, and large group exercise sessions that allow our clients to choose their preferred exercise environment. We have a community of patients who are experiencing their transition to wellness together. Many are Icon patients, who have seen impressive improvements in their health in just a small period.
One of Dr Coward’s patients has been undertaking group and one-on-one exercise classes with Valere Health since the start of 2019. He has exercised continually through chemotherapy, immunotherapy, targeted therapy, and in the lead up and following major surgery. Exercise has no doubt reduced the ill-feeling from side effects, but most of all has helped him endure through treatment and surgery and come out the other side. Individually tailored and safe exercise programs, created and delivered by experts in cancer and exercise, should be an essential part of every cancer patient’s treatment program.
If you’re interested in finding out more, ask Dr Coward how to get in touch with Morgan and Valere Health or visit the website http://valerehealth.com.au
Caring for your mental wellbeing and that of your loved ones during this time is just as important as caring for your physical wellbeing. Continuing to have hope and a positive outlook while riding this rollercoaster of the cancer journey is so very important but can sometimes be a very real struggle.
Support Services
Cancer Wellbeing Centre, Lilley Place
The Cancer Council also has available oncology trained psychological services, for face to face or over the phone support, for free. Contact them on 13 11 20
CanTeen have great mental health support, in person or online. For young people who have or are experiencing cancer in their lives. For Children and Young Adults (12-25yrs).
Sexual health can be a complex issue for both men, women and their partners. Body image, hormones, mood, desire, ability and pain are a few of the contributing factors. Problems may be caused from a variety of reasons – surgery, nerve damage, drug or radiation side effects, or psychological ‘blocks’ throughout the course of your treatment. Pain, dryness, physical appearance, function, endurance and stamina, libido and arousal are common problems encountered
For men, they may experience such things as erectile dysfunction and painful ejaculation, possible solutions could include hormones, medications, pump devices, lubricants or numbing cream.
For women, they may experience such things as vaginal dryness, vaginismus (tightening of the vagina) and thrush. Management options could include lubricants, dilators, medications or hormones.
Emotionally, psychologically and physically you have encountered big changes and challenges. Intimacy and sex is as much an emotional and mental experience (particularly for women) as it is physically, and is a significant part of most relationships. Consider counselling. Have open communication, patience and acceptance with your partner while you explore, experiment and adapt to these changes in your body to meet both your intimacy needs.
Other resources: While at the ICON clinic collect one of the Cancer Council’s booklets titled ‘Sexuality, Intimacy and Cancer’, request a referral to The Choices program or speak with the nurses.
Self Image, Sexuality and Cancer
Choices Cancer Support Centre – Located at The Wesley Hospital, open to anyone.
Hope Horizons Cancer Wellness Centre – For the Toowoomba and Darling Down Region.
CanTeen – Supporting youth between the age of 12-25 if they or a family member have cancer.
Redkite – Supporting a child under 18 with cancer and their family.
Men’s Shed – “Men don’t talk face to face, they talk shoulder to shoulder” Barry Golding.
Mummy’s wish – Supporting mum’s undergoing cancer treatment with children under the age of 12.
Self Help Queensland – database of support groups throughout Queensland.
For all other tumour types, please refer to Cancer Council Australia
While undergoing cancer treatment a variety of side effects can occur at different intervals, unique to each patient and drug regime. If not properly addressed their presence can significantly compromise your quality of life and ability to cope with your ongoing treatment. The best management of side effects is prevention and early intervention.
This list is by no means definitive but has some suggestions we often recommend, what works for one person may or may not work for another, likewise what has worked previously for you may not work the same way again. Your symptoms should be discussed with Dr Coward or your nurse as we monitor your progress, ensure appropriate management, maintain therapeutic ranges with drug doses and all options are being exhausted to improve your overall wellbeing.
Hair Loss (Alopecia) is likely to occur when on particular chemotherapies such as Taxanes, Alkylating agents and Anthracycline/DNA intercalating agents – this is because cells that replicate and mature quickly, such as hair follicles, are more susceptible to chemotherapy.
Scalp cooling is a therapy that works to prevent hair loss by reducing the blood flow to the follicles during treatment and limits the cells exposure to the chemotherapy agent, in the clinic we are able to provide access to the Paxman Cold Caps system to use in conjunction with your treatment.
Look Good Feel Better is a community based program with male, female and teenage focused workshops to provide support, education and demonstrations for managing appearance related side effects to treatment – including wigs, head scarves etc.
Insomnia – Having quality sleep for your body to recuperate may be difficult throughout treatment due to a variety of reasons from stress, mental and emotional fatigue, to medication induced hyperactivity. Sleep is essential to effectively cope mentally, emotionally and physically throughout the course of your treatment.
Steroids are often used throughout treatment and produce an increased irritability effect, if taken later in the day they often contribute to insomnia – take a twice daily dose morning and midday to early afternoon rather than morning and night.
Sedatives may be required to assist getting to or staying asleep for a longer period of time, there are many to choose from – natural preparations, over the counter tablets or prescription medications – taken each night or intermittently as appropriate to allow your body to gain the rest it requires.
Watery Eyes (Epiphora) Often caused by the Taxane group of drugs, let Dr Coward know of this as you may require steroid eye drops to treat.
Mouth Sores (Mucositis) includes anything from soreness to inflammation and ulcerations of the lining of your mouth, gums, oesophagus and lips. Problems here can lead to greater systemic problems such as weight loss, fatigue, electrolyte imbalance, dehydration and constipation, all because of your inability to eat well and drink enough fluids due to the pain caused.
Good dental hygiene is important from the onset as a preventative measure, using soft brushes (not electric) and regular non-alcohol based mouth washes – bicarb soda and water or preparations from a pharmacy.
For a dry mouth Biotene brand have a alcohol-free mouthwash with moisturising properties.
Ulcers can be stubborn, Bonjela and Xylocaine viscous can help numb the pain – useful prior to meal times to allow ease of eating. Pure Manuka honey, Gelclair and Kenalog can help to heal the ulcers. Ensure the manuka honey hasn’t crystallised as that will be painful to apply, gently warm to liquefy.
Any removable prosthetics in the mouth such as dentures or retainers check their fit, any rubbing or excessive pressure will likely be a source of future discomfort and breakdown.
Nausea is expected at some stage, you will be given some medications by pharmacy to take regularly or as required. This is not all you have available to you – it’s just the beginning. Nausea can be very debilitating, mentally, emotionally and physically. It can progress from nausea to anticipatory nausea, to vomiting and greatly affect your quality of life around treatment, complications include dehydration, electrolyte imbalance and if prolonged vomiting ulceration of the throat lining.
There are many options which can be taken alone or in combination with others. Each type of anti-nausea drug is designed to work differently and may come in either a tablet or wafer form. Metoclopramide, Ondansetron, Lorazepam, Prochlorpromazine are just a few to mention.
Non-pharmaceutical options include ginger or peppermint raw herbs, tablets or as a tea. Acupuncture and pressure points may also prove effective. Removing triggers that may instigate nausea such as particular smells, change habits when preparing to cook or attend appointments.
Sip fluids rather than drink a large volume in one sitting. If food sets off the nausea – take some medication (such as your Metoclopramide) at least 30 minutes before eating.
If you are concerned about your intake, weight loss or gain we are able to help refer you on to dietitian services.
Reflux or heartburn may become an issue, peppermint or ginger tea, antacids such as Mylanta,
Gavascon or Quickeze for intermittent relief. If it becomes a more persistent problem taking prescribed antacids daily may be required. Pay attention to what you eat and when the reflux occurs, identify and avoid the foods that may cause an episode. Take your time to eat, sit upright after meals for enough time to allow your stomach to empty before reclining or laying down.
Diarrhoea is common and can be quite taxing, contributing to other issues including fatigue, irritability, electrolyte imbalance and dehydration. Early intervention is the best management Loperamide tablets can be taken and titrated to severity, Codeine is also effective because of its side effect of constipation, low fibre diet may also be of assistance. Keep up your fluids with water and some electrolyte drinks. If you are on immunotherapies you need to contact Dr Coward as steroids may be required, likewise if the diarrhoea is prolonged and you are developing other symptoms (ie. temperatures, dizziness, confusion, severe cramping) please don’t hesitate to contact us or present to an emergency department.
Constipation is also very common and on the other spectrum to diarrhoea causing its own set of problems such as nausea, pain, bloating and possible obstruction. Constipation must be managed early and it’s a good idea to discuss with the nurses a plan that will work for you. Know your normal bowel habits, if you pass a motion every day and have missed a day then start introducing aperients to move things along. It is best to keep your stool on the softer side as it is often easier to slow motions down than to get them moving. Pay attention to which drugs may have a constipating effect and at what stage of your treatment cycle it tends to occur. A lot of the anti-nausea drugs and pain killers will cause constipation.
There are many options that will help you manage, it may take some trial and error to begin with to see what works best for you. Dietary intervention can include prunes, prune or pear juice (warm liquids have been known to be more effective that having them cold). Keep well hydrated – the bowel uses a lot of water and the consistency of your stool can dramatically change dependant on what is available. High fibre diets increase the roughage to pull the water into the bowel and keep wastes moving through. Food based fibre preparations such as Nu-lax or Metamucil can help on a day to day basis. Laxatives from a chemist come in a large range some being Ducolax, Coloxyl & Senna, Movicol, Osmolax and Picolax are some oral tablets and solutions. Enemas may also be required (or a combination of both) such as a Microlax or Fleet. Laxatives require water to work; their effectiveness lies in how early and how much is taken along with 2-3 litres of water a day.
Hot flushes related to medications or hormone changes may be problematic, acupuncture, evening primrose oil or a low dose of Efexor may assist. Wear light cotton clothing to allow sweat to evaporate.
Skin rashes often occur with the Taxanes and anti-eGFR agents such as Cetuximab. Avoid the sun, soap and alcohol based products that will dry the skin, avoid perfume based creams and choose products for sensitive skin or paraffin based. Some brands such as Cetaphil has a range of products that are better tolerated. Steroids are often required usually in the form of a cream but tablets may also be required dependant on severity. Use antihistamines to treat itching and cold compresses to sooth pain and irriation.
Neuropathy particularly a problem with the Taxane and Platin drugs, is an unpleasant side effect that affects the hands and/or feet with numbness, tingling and/or pain, as the neuropathy increases in severity it can affect your walking and fine motor skills, compromising your quality of life, and may not be fully restored post treatment. You need to keep Dr Coward up to date on the progress of any neuropathy as it will impact the amount of drug you are able to receive, you will be closely monitored and adjustments to treatment will be made as necessary.
Vitamin B12 injections once a month may help to protect the nerve endings, ice gloves, or bands around the wrist and ankles could have some effect and low dose antidepressants may also assist in management. You can also use any course material, such as a face cloth or nail brush, to rub on your hands/feet to stimulate the nerve endings – when used while in pain it can be uncomfortable to start with but with persistence has helped to provide some relief.
Muscular cramps can occur as a result of the treatment, fatigue, lack of exercise, decreased muscle tone and electrolyte changes. INDIAN tonic water is great as it contains quinine which can help to relieve cramps with prescribed magnesium supplements if appropriate. Gentle exercise throughout the day and stretching particularly in the evening before bed may also alleviate the discomfort.
Fatigue is a significant problem experienced by everyone, caused by a variety of factors, most commonly emotional, mental and physical stress from the onset of investigation and diagnosis through your treatment; the drugs in your treatment regime and the side effects experienced. There is a difference between fatigue and tiredness. Take the time to rest when your body tells you you need it, this is heavy treatment you are undergoing and an extremely stressful life event.
Quality rest and sleep allows your body and mind to rejuvenate and heal.
Make time and push through the lack of motivation to do some exercise, walk around the block, along the beach, in the pool, lift some gentle weights. Not only does this maintain muscle tone, but also gets you outside into the fresh air and daylight, exercise produces endorphins which lift your mood, improves cardiovascular function and improves treatment related fatigue. Patients who have persisted with some form of exercise throughout their treatment and afterwards have recovered faster and coped better with side effects and the mental and emotional turmoil. Utilise a physiotherapist for a specific regime tailored to you.
Maintain a well balanced diet, with plenty of fruits and vegetables to provide the nutrients you need, including adequate hydration each day.
Utilise a counsellor, for yourself and also for your family members, to work through the challenges that you are currently facing. Family and friends are often available and very supportive. However don’t underestimate the value of speaking to someone who is familiar to cancer care and is objective and not affected by you sharing how you are feeling and some rational or irrational thoughts you may be having. A counsellor provides an opportunity for you and/or your family members to vent frustrations in a safe place, thoughts and concerns that may cause more distress to loved ones if shared but need to be expressed for acceptance and being able to move forward.
Some people wish to continue working as they are able, talk with your employer about how things are going and if you wish to continue to work throughout your treatment, discuss a plan to make a few changes to the hours, days, location, tasks you do to accommodate what you are able to effectively accomplish.