Dr. Lenz

I wanted to share with you an amazing story which began a few weeks ago.  A 28 year old woman with metastatic colon cancer with intra-abdominal spread came for a second opinion. She is well-educated and knows what she wants. She already had two opinions from the National Institutes of Health and the University of California at San Diego, and was open to hear what we would suggest.

I love patients who are informed (although it does not necessarily mean they have all the statistics and data correct). The discussion can move more quickly to create a plan, and there is no need to spend much time on the basics. But sometimes the problem with having a lot of information, especially from the internet and all the good friends you have, is prioritizing it. You have to decide what is the most important, what is validated, and what is a scam.

For this patient, we decided to do genetic testing on the tumor then select chemotherapy based on the results. We wrote a review putting all the data together, and recommended that the patient see Dr. Paul Sugarbaker, a surgeon who specializes in gastrointestinal oncology, after her chemotherapy treatment.

This patient was well-informed, with a very supportive family. We connected her with another young patient who had metastatic disease in the abdominal cavity and has been cancer-free for 18 months. They were able to talk and put the information on a different level. Many patients struggle with all the overwhelming information, and have a hard time deciding what to do with so many, and often contradictory, recommendations.

The patient decided to deal with the disease head-on. She was proactive and put down her experiences in a blog. I don’t know if writing a blog is helpful for all patients, but it is for her. To identify and articulate the processes and challenges is the first step to overcome them. Personally, I am very proud that WUNDER is part of the blog’s name – it is the German word for miracle – and we’re doing all we can to make this another miracle.

There are many blogs and chat rooms which are important for our patients. Two good ones are the Colon Club as well as the Colon list at ACOR.org. Doctors can do so much, but without patients helping each other, we are much less successful. THANK YOU ALL.

Dr. Lenz

The short answer is YES, but obviously this depends on many factors. We usually recommend that patients complete one or two cycles of chemotherapy to see if there are many side effects or not. If patients tolerate the first two cycles well, usually there is no accumulating side effect expected except for neurotoxicity with oxaliplatin down the road.

Personally I think going back to work is important, because it gives the patient some normality and forces him or her to think about something else than the cancer. However this may not apply for everyone, so discussions with your doctor and family are critical. It is important to plan how you will continue to work while you get cancer treatment. I see patients on Mondays and Thursdays, so patients who want to continue to work or may have to continue to work to keep their insurance, usually get treatments on Thursdays, giving them the weekend to recover. Patients who want to spend the weekend with the family choose Monday treatments, giving them time to recover for the weekend. Here are some tips which might help you to better manage your time and work:

• Evaluate working hours. Can you be flexible, so that most meetings or work can be in the second week of therapy and so that you can leave early in the first week if you are feeling sick?
• Getting help at home can save more energy for work. Ask friends and family members to alternate with helping shopping, bringing kids to school or events, etc.
• Consider talking with your boss and co-workers know about your situation. They can help with your work schedule and be supportive to make your work more manageable during this time.
• Learn to delegate job duties so you can direct others in handling tasks when you’re out of the office.

You have the same rights as anyone else in the workplace and should be given equal opportunities, regardless of whether or not you tell people at work about your cancer. Hiring, promotion, and how you are treated in the workplace should depend entirely on your ability and qualifications. As long as you are able to fulfill your job duties, you cannot be fired for being sick. Also, you should not have to accept a position that you never would have considered before your illness. Some people with job problems related to cancer are protected by federal laws like the Rehabilitation Act and the Americans with Disabilities Act. Some people also benefit from the Family and Medical Leave Act (FMLA), which allows many people with serious illnesses to take unpaid leave for medical care or to manage their symptoms. The leave can take many forms, such as a part-time schedule for a limited time, or taking off 1 or 2 days per week for a while. Not all employers are required to follow FMLA. Talk to someone in your human resources department or another workplace expert to find out what your options are.

It is unbelievable how many patients in my practice suffer from insomnia and are taking sleeping medications. I thought I’d share with you some alternatives which may help you to get a restful sleep.

Many sleeping medications make you sleep but don’t allow you to really rest. They take away your dream/REM pattern which is necessary to get the feeling of rest. Those who fall asleep easily and sleep through the night are the lucky ones.

By definition, insomnia is “difficulty initiating or maintaining sleep, or both” and it may be due to inadequate quality or quantity of sleep. It is typically followed by functional impairment while awake. The pattern of insomnia often is related to the etiology.  Insomnia affects 1 in 3 people.

1. Onset insomnia: Difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
2. Middle-of-the-night insomnia:  Insomnia characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning, also referred to as nocturnal awakenings, encompasses middle and terminal insomnia.
3. Middle insomnia: Waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness.
4. Terminal (or late) insomnia: Early morning waking. Often a characteristic of clinical depression.

Insomnia can be caused by many medications such as  psychoactive drugs or stimulants, including certain medications, herbs, caffeine, cocaine, ephedrine, amphetamines, methylphenidate, MDMA (also known as ecstasy), methamphetamine and modafinil. Some antibiotics can also cause chronic insomnia such as Levaquin® (levofloxin).

It is easy to understand that anxiety, stress (emotional, financial or sexual) and fear can cause you difficulty sleeping. We also know that jet lag or working night shifts can impact your sleep at some times of the day and cause excessive sleepiness at other times of the day.

If chronic insomnia exists specific medical conditions should be ruled out such as  hyperthyroidism or rheumatoid arthritis. Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven. A healthy diet containing magnesium may help to improve sleep in individuals without an adequate intake of magnesium.

Insomnia in women seems to be linked at least partly to lower estrogen levels, which is a potential reason why women often tend to develop insomnia at menopause. Estrogen helps with the uptake of magnesium into the soft tissues. If estrogen levels are low, magnesium deficiencies and conditions they can cause such as insomnia, heart palpitations, anxiety and fibromyalgia may become more problematic. Make sure you have seen your gynecologist to discuss estrogen replacement strategies.

As mentioned, insomnia can be caused by many other diseases, side effects from medications, or psychological problems. To be able to treat insomnia effectively, it is critical to find out all medical and psychological conditions before starting any medications. Obviously it is necessary to assure that there is an appropriate sleep hygiene which basically means no noise or other environmental factors leading to sleep disruptions.

Please discuss medication therapies with your oncologists.

However you might consider to explore some alternative options which you need to share with your treating physician. For example, when I am traveling I usually take 3 mg of melatonin to avoid jet lag, which seems to work for me. Melatonin is available over the counter but also in prescription form known as Rozerem® (ramelteon). These drugs seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. While these drugs show good effects for the treatment of insomnia due to jet lag, the results for other forms of insomnia are less promising.

There are a number of herbal mixtures which have been suggested to have some modest effects including valerian, chamomille, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.

There is more you can try by changing the way you arrange your lifestyle. These include changing your sleep area or schedule, watching what and when you eat and drink, and being more active. It’s also important to keep regular bedtimes and wake times seven days a week and to try to avoid taking naps during the day.

A Harvard Medical School study found that yoga improved the study participants overall quality of sleep, including helping people to fall asleep easier and stay sleeping for longer periods. A study published in the Journal of the American Geriatrics Society found that elderly adults with moderate sleep complaints improved self-rated sleep quality through a low to moderate intensity Tai chi program conducted for six months.