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Cancer Treatment

Part 2: Diet, Pain Management, and Support Services

Volume 8, Number 5 - July 2004

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

Download PDF version of this Newsletter [217K]

Inside HealthHints....

• Cancer Treatment
• Diet and Cancer
• Alcoholic Beverages and Cancer
• Side Effects and Associated Diet Recommendations
• Vitamin Supplements?
• Meal Replacements
• An Important Note About Food-borne Illness
• Managing Pain
• Methods of Pain Relief
• Does Cancer Treatment Hurt?
• When You Need Support
• The Truth About Hospice Care Services
• Support Services Contact Information
• Website Resources You May Find Useful
• References

Cancer Treatment: Diet, Pain Management, and Support Services

In the last issue of HealthHints we discussed how to support your loved one as they face four primary types of cancer treatment (i.e., surgery, chemotherapy, radiation therapy, and immunotherapy). In this issue of HealthHints we will look at how to support those with cancer as related to managing diet, pain, and where to go when further support is needed.

Diet and Cancer: Ensuring Proper Nutrition

Once a cancer has developed, there is no known cure to treat it through diet alone. Individuals should be particularly wary of any dietary advice that would prohibit certain foods or food groups. There is no single food guaranteed to cause or prevent cancer, although communities that eat high-fiber, low-fat diets have shown lower rates of certain types of cancer, such as bowel cancer (The Cancer Council Victoria, 2004b). If the right balance of nutrients is not consumed through a balanced diet, however, other health problems may result and interfere with the success of medical treatment (The Cancer Council Victoria, 2004b). For information on what entails a normal "balanced diet" see the food guide pyramid and corresponding information at http://www.nal.usda.gov/fnic/Fpyr/pyramid.html. Note that diet for the cancer patient may deviate from these guidelines significantly during treatment and not only is this okay, it is important for the management of the patient's health.

Although there are no special foods that must be used or avoided completely when a person has cancer, there are probably some changes every person can make to ensure getting proper nutrition, and that may help in overcoming any eating problems that may develop as a result of the cancer or cancer treatment (The Cancer Council Victoria, 2004b).

Some problems that may arise as a result of cancer treatment, which can contribute to problems with diet include:

• weight loss
• weight gain
• loss of appetite
• increased appetite
• changes in sense of taste or smell
• mouth sores, dry mouth, or dental problems
• diarrhea
• constipation
• nausea/vomiting
• lactose intolerance
• fatigue and/or depression (National Cancer Institute, 2004a).

Some people may experience unwanted weight gain during cancer treatment due to increased appetite, changes in body metabolism, increased fluid retention, or some combination of these side effects. This is particularly true for breast, prostate, and ovarian cancer patients taking certain medications or who are on hormone therapy or chemotherapy (National Cancer Institute, 2004a). Generally, weight loss efforts should not be undertaken during cancer treatment, since this is a time when the body is undergoing stress. It is important to maintain an adequate, well-balanced diet during cancer treatment. The best time to lose weight is after treatment is completed and the body has had time to recover from any side effects experienced (The Cancer Council Victoria, 2004c).

Other people will commonly experience weight loss with cancer treatment, due to loss of appetite, discomforts of the mouth, nausea/vomiting, diarrhea, fatigue, depression, and reduced activity. Weight is usually lost from muscle rather than fat stores and needs to be controlled if possible (The Cancer Council Victoria, 2004c). Smoking can also reduce appetite at a time when additional nutrition is needed -- if you haven't yet quit smoking, it's not too late (American Cancer Society, 2004c).

Eating well means having a diet high enough in calories to keep weight up and high enough in protein to rebuild tissues that cancer treatment may harm. People who eat well cannot only cope with side effects and fight infection better, but give their bodies the chance to rebuild healthy tissue faster (National Cancer Institute, 1999).

A registered dietitian can be the cancer patient's best source of information about diet. If you cannot get a referral, call the American Dietetic Association's (ADA) toll free hotline at 1-800-366-1655.

Side Effects and Associated Diet Recommendations: Tips for Getting Through Tough Times

The following information is adapted from the National Cancer Institute's publication "Eating Hints for the Cancer Patient: Before, During, and After Treatment." This publication is invaluable for helpful information about diet and cancer and is recommended in its entirety for those undergoing cancer treatment and/or their loved ones. See Eating Hints for the Cancer Patient: Before, During, and After Treatment in its entirety at http://www.cancer.gov/cancertopics/eatinghints.

Recommendations about food and eating for cancer patients can be very different from the usual suggestions for healthful eating. This can be confusing for many patients because these new suggestions may seem to be the opposite of what they've always heard. Nutrition recommendations usually stress eating lots of fruits, vegetables, and whole grain breads and cereals; including a moderate amount of meat and dairy products; and cutting back on fat, sugar, alcohol, and salt.

Though the cancer patient will likely go back to following these dietary guidelines after treatment when side effects have subsided, nutrition recommendations for cancer patients may focus on helping the patient eat more higher calorie foods that emphasize protein. Recommendations might include eating or drinking more protein-rich foods such as milk, cream, cheese, and cooked eggs. Other suggestions might include increasing use of sauces and gravies, or changing cooking methods to include more butter, margarine, or oil to increase rather than reduce calorie intake. Sometimes, nutrition recommendations for cancer patients suggest that you eat less of certain high-fiber foods because these foods can aggravate problems such as diarrhea or a sore mouth.

Nutrition recommendations for cancer patients are different because they are designed to help build up strength and help withstand the effects of cancer and its treatment. When you are healthy, eating enough food to get the nutrients you need is usually not a problem. During cancer treatment, however, this can become a challenge, especially if you have side effects or simply don't feel well.

Tips Before Treatment

Think Positively

• Many people have few or no eating-related side effects. Even if you do, they may be mild, and most go away after cancer treatment ends. Also, there are new drugs now that can work well to control side effects. Having a positive attitude, talking out your feelings, becoming well-informed about your cancer and treatment, and planning ways to cope can all help reduce worry and anxiety, make you feel more in control, and help you keep your appetite.
• Give food a chance. Even if you do have eating problems, you'll have days when eating is a pleasure.

Eat a Healthy Diet

• A healthy diet is vital for a person's body to work its best. This is even more important for cancer patients. If you've been eating a healthy diet, you'll go into treatment with reserves to help keep up your strength, prevent body tissue from breaking down, rebuild tissue, and maintain your defenses against infection.
• People who eat well are better able to cope with side effects. You may even be able to handle higher doses of certain treatments. For example, we know that some cancer treatments are actually much more effective if the patient is well-nourished and getting enough calories and protein in his or her diet.
• Don't be afraid to try new foods. Some things you may never have liked before may taste good to you during treatment.

Plan Ahead

• Stock the pantry and freezer with favorite foods so that you won't need to shop as often. Include foods you know you can eat even when you are sick.
• Keep foods handy that need little or no preparation, for example, pudding, peanut butter, tuna fish, cheese, and eggs.
• Do some cooking in advance and freeze in meal-sized portions.
• Talk to friends or family members about helping with shopping and cooking. Or, ask a friend or family member to manage that job for you.
• Talk to a registered dietitian about your concerns and what you might expect. He or she can give you ideas and help you plan meals. Ask for help in developing a grocery list with foods that might help with potential side effects, such as constipation or nausea. Ask about what has worked for other patients.

General Nutrition Tips

Remember, there aren't any hard and fast nutrition rules during cancer treatment. Some patients may continue to enjoy eating and have a normal appetite throughout most of their cancer treatment. Others may have days when they don't feel like eating at all; even the thought of food may make them feel sick. Here are some things to keep in mind:

• When you can eat, try to eat meals and snacks with sufficient protein and calories; they will help you keep up your strength, prevent body tissues from breaking down, and rebuild tissues that cancer treatment may harm (see Eating Hints for the Cancer Patient: Before, During, and After Treatment at http://www.cancer.gov/cancertopics/ eatinghints for examples of protein-rich foods).
• Many people find their appetite is better in the morning. Take advantage of this and eat more then. Consider having your main meal of the day early, and have liquid meal replacements later on if you don't feel so interested in eating (talk with your registered dietitian about liquid meal replacements that may be right for you).
• If you don't feel well and can eat only one or two things, stick with them until you are able to eat other foods. Try a liquid meal replacement for extra calories and protein.
• On those days when you can't eat at all, don't worry about it. Do what you can to make yourself feel better. Come back to eating as soon as you can, and let your doctor know if this problem doesn't get better within a couple of days.
• Try to drink plenty of fluids, especially on those days when you don't feel like eating. Water is essential to your body's proper functioning, so getting enough fluids will ensure that your body has the water it needs. For most adults, 6 to 8 cups of fluid a day are a good target. Try carrying a water bottle with you during the day. That may help you get into the habit of drinking plenty of fluids. Try fluids other than water, too (see Eating Hints for the Cancer Patient: Before, During, and After Treatment at http://www.cancer.gov/cancertopics/eatinghints for examples).

Tips for Loss of Appetite

For some people, loss of appetite happens for just a day or two; for others, it's an ongoing concern. Whatever the reason, here are some suggestions that might help:

• Try liquid or powdered meal replacements, such as "instant breakfast," during times when it is hard for you to eat food.
• Try frequent small meals throughout the day, rather than fewer big ones. It may be easier to eat more that way, and you won't get so full.
• Keep snacks within easy reach so you can have something whenever you feel like it. Cheese and crackers, muffins, ice cream, peanut butter, fruit, and pudding are good possibilities. Take a portable snack with you when you go out, such as peanut butter crackers or small boxes of raisins.
• Even if you don't feel like eating solid foods, try to drink beverages during the day. Juice, soup, and other fluids like them can give you important calories and nutrients. Milk-based drinks also provide protein.
• If possible, try having something at bedtime. It won't affect your appetite for the next meal.
• Sometimes, changing the form of a food will make it more appetizing and help you eat better. For example, if eating whole, fresh fruit is a problem, try mixing fruit into a milkshake.
• Try softer, cool, or frozen foods, such as yogurt, milkshakes, or popsicles.
• Take advantage of times when you do feel well, and have a larger meal then. Many people have a better appetite first thing in the morning, when they are well rested.
• During meals, sip only small amounts because drinking may make you feel full. If you want to have more than just a small amount to drink, have it 30 to 60 minutes before or after a meal.
• Make mealtimes as relaxed and pleasant as possible. Presenting food or meals in an attractive way may also help.
• If your doctor allows, have a small glass of wine or beer during a meal. It may help to stimulate your appetite. It is very important to consult your doctor about any alcohol consumption since some treatments can be affected by alcohol.
• Regular exercise may help your appetite. Check with your doctor to see what options are open to you.

Tips About Weight Gain

Sometimes weight gain occurs because certain anticancer drugs create a condition called edema in which the body holds onto excess fluid. If this is the case, you may want to ask your doctor or registered dietitian about limiting the amount of salt you eat. Weight gain may also be the result of increased appetite and eating extra food and calories. If this is the case, and you want to stop gaining weight, here are some tips that can help. Remember, your goal is to regain your strength and health, not to worry about weight loss at this time. Talk to a registered dietitian for more guidance:

• Emphasize fruits, vegetables, and breads and cereals.
• Choose lean meats (lean beef or pork trimmed of fat, chicken without skin) and low-fat dairy products (skim or 1% milk, light yogurt).
• Cut back on added butter, mayonnaise, sweets, and other extras.
• Choose low-fat and low-calorie cooking methods (broiling, steaming).
• Avoid eating high-calorie snacks between meals.
• If you feel up to it, increase the amount of exercise you get.

Tips for Sore Mouth or Throat

Mouth sores, tender gums, and a sore throat or esophagus often result from radiation therapy, chemotherapy, or infection. If you have a sore mouth or gums, see your doctor to be sure the soreness is a treatment side effect and not an unrelated dental problem. The doctor may be able to give you medicine that will control mouth and throat pain. Your dentist also can give you tips for the care of your mouth. Certain foods will irritate an already tender mouth and make chewing and swallowing difficult. By carefully choosing the foods you eat and by taking good care of your mouth, teeth, and gums, you can usually make eating easier. Here are some suggestions that may help:

Try soft foods that are easy to chew and swallow, such as:

• milkshakes
• bananas, applesauce, and other soft fruits
• peach, pear, and apricot nectars
• watermelon
• cottage cheese, yogurt
• mashed potatoes, noodles
• macaroni and cheese
• custards, puddings, and gelatin
• scrambled eggs
• oatmeal or other cooked cereals
• pureed or mashed vegetables, such as peas and carrots
• pureed meats

Avoid foods or liquids that can irritate your mouth. These include:

• oranges, grapefruits, lemons, or other citrus fruit or juice
• tomato sauces or juice
• spicy or salty foods
• raw vegetables, granola, toast, crackers, or other rough, coarse, or dry foods
• commercial mouthwashes that contain alcohol

Prepare foods for more comfortable eating:

• Cook foods until they are soft and tender.
• Cut foods into small pieces.
• Use a blender or food processor to puree your food.
• Mix food with butter, margarine, thin gravy, or sauce to make it easier to swallow.
• Use a straw to drink liquids.
• Use a smaller-than-usual spoon, such as a baby spoon.
• Try foods cold or at room temperature. Hot foods can irritate a tender mouth and throat.
• Try drinking warm bouillon or salty broth; it can soothe throat pain.
• Try sucking on ice chips.
• If swallowing is hard, tilting your head back or moving it forward may help.
• If your teeth and gums are sore, your dentist may be able to recommend a special product for cleaning your teeth.
• Rinse your mouth often with water to remove food and bacteria and to promote healing.
• Ask your doctor about anesthetic lozenges and sprays that can numb your mouth and throat long enough for you to eat meals.

Tips for Dry Mouth

Chemotherapy and radiation therapy in the head or neck area can reduce the flow of saliva and cause dry mouth. When this happens, foods are harder to chew and swallow. Dry mouth also can change the way foods taste. Some of the ideas for sore mouth and throat may help. The suggestions below also may help you deal with dry mouth.

• Have a sip of water every few minutes to help you swallow and talk more easily. Consider carrying a water bottle with you so you always have some handy.
• Try very sweet or tart foods and beverages, such as lemonade; these foods may help your mouth make more saliva. (Do not try this if you also have a tender mouth or sore throat and the sweet or tart foods make it worse.)
• Suck on hard candy or popsicles or chew gum. These can help make more saliva.
• Eat soft and pureed foods, which may be easier to swallow.
• Keep your lips moist with lip salves.
• Moisten food with sauces, gravies, and salad dressings to make it easier to swallow.
• If your dry mouth problem is severe, ask your doctor or dentist about products that coat, protect, and moisten your mouth and throat. These are sometimes called "artificial saliva."
• For other mouth, dental, or gum problems, consult your doctor and/or dentist.

Tips for Taste and Smell Issues

There is no foolproof way to prevent changes to your sense of taste or smell because each person is affected differently by illness and treatments. However, the tips below should help if you have this problem.

• Choose and prepare foods that look and smell good to you.
• If red meat, such as beef, tastes or smells strange, try chicken, turkey, eggs, dairy products, or mild-tasting fish instead.
• Help the flavor of meat, chicken, or fish by marinating it in sweet fruit juices, sweet wine, Italian dressing, or sweet-and-sour sauce.
• Try using small amounts of flavorful seasonings, such as basil, oregano, or rosemary.
• Try tart foods, such as oranges or lemonade, that may have more taste. A tart lemon custard might taste good and will also provide needed protein and calories. (If you have a sore mouth or throat, tart or citrus foods might cause pain or discomfort.)
• If smells bother you, try serving foods at room temperature, turning on a kitchen fan, covering foods when cooking, and cooking outdoors in good weather.
• Try using bacon, ham, or onion to add flavor to vegetables.
• Visit your dentist to rule out dental problems that may affect the taste or smell of food.
• Ask your dentist or doctor about special mouthwashes and good mouth care.

Tips for Nausea

Nausea, whether caused by cancer treatment or the cancer itself, can keep you from getting enough food and needed nutrients. Ask your doctor about antiemetics, drugs that might help you control nausea and vomiting. Here are some other ideas that can help:

Try foods that are easy on your stomach, such as:

• toast, crackers, and pretzels
• yogurt
• sherbet
• angel food cake
• cream of wheat, rice, or oatmeal
• boiled potatoes, rice, or noodles
• skinned chicken that is baked or broiled, not fried
• canned peaches or other soft, bland fruits and vegetables
• clear liquids
• ice chips
• carbonated drinks

Avoid foods that:

• are fatty, greasy, or fried
• are very sweet, such as candy, cookies, or cake
• are spicy or hot
• have strong odors
• Eat small amounts, often and slowly. Eat before you get hungry, because hunger can make feelings of nausea stronger.
• If nausea makes certain foods unappealing, then eat more of the foods you find easier to handle.
• Avoid eating in a room that's stuffy, too warm, or has cooking odors that might disagree with you.
• Drink fewer liquids with meals. Drinking liquids can cause a full, bloated feeling.
• Slowly drink or sip liquids throughout the day. A straw may help.
• Have foods and drinks at room temperature or cooler; hot foods may add to nausea.
• Don't force yourself to eat favorite foods when you feel nauseated. This may cause a permanent dislike for those foods.
• Rest after meals, because activity may slow digestion. It's best to rest sitting up for about an hour after meals.
• If nausea is a problem in the morning, try eating dry toast or crackers before getting up.
• Wear loose-fitting clothes.
• If nausea occurs during radiation therapy or chemotherapy, avoid eating for 1 to 2 hours before treatment.
• Try to keep track of when your nausea occurs and what causes it (specific foods, events, surroundings). If possible and if it helps, change your diet or schedule. Share the information with your doctor or nurse.

Vomiting

Vomiting may follow nausea and may be brought on by treatment, food odors, gas in the stomach or bowel, or motion. If vomiting is severe or lasts for more than a day or two, contact your doctor. He or she may give you an antiemetic medication to control nausea and vomiting. Very often, if you can control nausea, you can prevent vomiting. At times, though, you may not be able to prevent either. Relaxation exercises or meditation may help you. These usually involve deep rhythmic breathing and quiet concentration, and can be done almost anywhere. If vomiting does occur, try these suggestions to help prevent further episodes:

• Do not eat or drink anything until you have the vomiting under control.
• Once the vomiting is under control, try small amounts of clear liquids, such as water or bouillon. Begin with 1 teaspoonful every 10 minutes, gradually increasing the amount to 1 tablespoon every 20 minutes. Finally, try 2 tablespoons every 30 minutes.
• When you are able to keep down clear liquids, try a full-liquid diet or a soft diet (see Eating Hints for the Cancer Patient: Before, During, and After Treatment at http://www.cancer.gov/cancertopics/eatinghints for soft and liquid diet examples). Continue taking small amounts as often as you can keep them down. If you feel okay, gradually work up to your regular diet. If you have a hard time digesting milk, you may want to try a soft diet instead of a full-liquid diet, because a full-liquid diet includes a lot of milk products. Ask a registered dietitian for information about a soft diet.

Diarrhea

During diarrhea, food passes quickly through the bowel before your body has a chance to absorb enough vitamins, minerals, and water. This may cause dehydration, which means that your body does not have enough water to work well. Long-term or severe diarrhea may cause problems, so contact your doctor if the diarrhea is severe or lasts for more than a couple of days. Here are some ideas for coping with diarrhea:

• Drink plenty of fluids to replenish what you lose with the diarrhea.
• Eat small amounts of food throughout the day instead of three large meals.
• Eat plenty of foods and liquids that contain sodium and potassium, two important minerals that help your body work properly. These minerals are often lost during diarrhea. Good high-sodium liquids include bouillon or fat-free broth. Foods high in potassium that don't cause diarrhea include bananas, peach and apricot nectar, and boiled or mashed potatoes. Sports drinks contain both sodium and potassium and have easily absorbable forms of carbohydrates.

Try these foods:

• yogurt, cottage cheese
• rice, noodles, or potatoes
• farina or cream of wheat
• eggs (cooked until the whites are solid; not fried)
• smooth peanut butter
• white bread
• canned, peeled fruits and well-cooked vegetables
• skinned chicken or turkey, lean beef, or fish (broiled or baked, not fried)

Avoid:

• greasy, fatty, or fried foods if they make your diarrhea worse
• raw vegetables and the skins, seeds, and stringy fibers of unpeeled fruits
• high-fiber vegetables, such as broccoli, corn, dried beans, cabbage, peas, and cauliflower
• very hot or cold food or beverages. Drink liquids that are at room temperature.
• Limit foods and drinks that contain caffeine, such as coffee, some sodas, and chocolate.
• If you have a sudden, short-term attack of diarrhea, try having nothing but clear liquids for the next 12 to 14 hours. This lets your bowel rest and replaces the important fluids lost during the diarrhea. Make sure your doctor or nurse knows about this problem.
• Be careful when using milk and milk products. The lactose they contain can make diarrhea worse. Most people, though, can handle small amounts (about 1 1/2 cups) of milk or milk products.

Lactose Intolerance

Lactose intolerance means that your body can't digest or absorb the milk sugar called lactose. Milk, other milk-based dairy products (such as cheese and ice cream), and foods to which milk has been added (such as pudding) may contain lactose. Lactose intolerance may occur after treatment with some antibiotics, with radiation to the stomach or with any treatment that affects the digestive tract. The part of your intestines that digests lactose may not work properly during treatment. For some people, the symptoms of lactose intolerance (gas, cramps, diarrhea) disappear a few weeks or months after the treatments end or when the intestine heals. For others, a permanent change in eating habits may be needed.

If you have this problem, your doctor may advise you to follow a diet that is low in foods that contain lactose. Talk to a registered dietitian to get advice and specific tips about how to follow a low-lactose diet. Your supermarket should carry milk and other products that have been modified to reduce or eliminate the lactose.

Constipation

Some anticancer drugs and other drugs, such as pain medications, may cause constipation. This problem also can occur if your diet lacks enough fluid or fiber, or if you've been in bed for a long time. Here are some suggestions for preventing and treating constipation:

• Drink plenty of liquids -- at least eight 8-ounce glasses every day. This will help to keep your stools soft. Another way to think about fluids is to try to drink at least 1/2 ounce per pound of your body weight.
• Have a hot drink about one-half hour before your usual time for a bowel movement.
• Check with your doctor to see if you can increase the fiber in your diet (there are certain types of cancer for which a high-fiber diet is not recommended). If you can, try foods such as whole-grain breads and cereals, dried fruits, wheat bran, wheat germ; fresh fruits and vegetables; dried beans and peas. Eat the skin on potatoes. Make sure you also drink plenty of fluids to help the fiber work.
• Get some exercise every day. Talk to your doctors or a physical therapist about the amount and type of exercise that's right for you.

If these suggestions don't work, ask your doctor about medicine to ease constipation. Be sure to check with your doctor before taking any laxatives or stool softeners.

Fatigue and Depression

Fatigue and depression aren't eating problems in and of themselves, but they can affect your interest in food and your ability to shop and prepare healthy meals. Here are some suggestions that may help:

• Talk about your feelings and your fears. Being open about your emotions can make them seem more manageable. Consider talking with your nurse or social worker, who can help you find ways to lessen your worries and fears.
• Become familiar with your treatment, possible side effects, and ways of coping. Being knowledgeable and acting on that knowledge will help you feel more in control. Don't be afraid to talk with your doctor and ask questions.
• Make sure you get enough rest -- take several naps or rest breaks during the day, rather than one long rest; plan your day to include rest breaks; make rest time special with a good book in a comfortable chair or a favorite video with a friend.
• Try easier or shorter versions of your usual activities; don't push yourself to do more than you can manage.
• Save your favorite foods for times that aren't associated with treatment sessions. That way, they won't be linked to an uncomfortable or distressing event.
• Take short walks or get regular exercise, if possible. Some people find this helps to lessen their fatigue and raise their spirits.

Special Notes for Caregivers

There is much that you can do to help your friend or loved one through the period of cancer treatment. Read over the tips and suggestions above. Many may be useful to you as you prepare food or meals for the patient. In addition, here are some other things to remember that will help you cope:

• Be prepared for the patient's tastes to change from day to day. Some days he or she won't want favorite foods because they don't taste good. Other times, he or she will be able to eat a dish that couldn't be
  tolerated just the day before.
• Have food within easy reach at home. For example: a snack-pack of applesauce or pudding and a spoon on the bedside table if the patient isn't feeling well that day, or a bag of cut-up carrots on the top shelf of the refrigerator.
• Have meals and snacks ready so the patient can have something to eat when he or she is ready.
• Be prepared for times when the patient is able to eat only one or two foods for a few days in a row, until side effects diminish. Even if he or she can't eat at all, still encourage plenty of fluids.
• Talk to the patient about needs and concerns, and about ideas that might work best. A willingness to be flexible and supportive no matter what will help the patient feel in control of the situation.
• Try not to push the patient into eating and drinking. Encourage and support without being overwhelming (National Cancer Institute, 2004a).

Managing Pain: The Right to Relief

Wanting to control pain is not a sign of weakness. The cancer patient deserves to get relief from pain. It is a way to help the patient feel better and stay active (National Cancer Treatment, 2004b). Cancer pain can almost always be relieved. The best way to control cancer pain is to prevent it from starting or getting worse. Treating cancer pain early is the best way to get relief. Don't try to hold off on talking about it or between doses of pain medication -- pain may get worse and may require larger doses of medication or take longer to get relief. As a cancer patient, you have a right to pain relief -- ask for it (National Cancer Institute, 2000a).

Here are four important aspects of cancer pain management:

1. Most pain can be controlled.
2. Communication is vital.
3. Pain can be measured.
4. The patient, family, and health care team can work together to control pain (National Cancer Institute, 2004c).

Cancer pain may be caused by the cancer itself or by side effects from treatment. Cancer pain may vary in type (e.g., muscle, bone, organ, nerve, other complications) and in severity. People with the same type of cancer and undergoing the same treatment may experience different types and levels of pain. Some people may experience little to no pain.

Good communication is vital in managing pain. Some patients worry they are being a bother to their medical team; older patients may not speak up because they feel their pain is unrelated to cancer (e.g., arthritis pain) (National Cancer Treatment, 2004b). Whatever your concerns -- speak up. Your medical care team is there to help you. Only you can convey how much pain you are having. If it helps, talk with a friend or family member first and have them help convey the information to your medical provider.

Gather information to help your care providers measure the severity and type of pain. You can do this by answering the following questions:

• On a scale of 0 to 10 (0 being no pain, 10 being the worst pain imaginable) how would you rate your pain?
• Does the pain move around or stay in one place?
• Where do you feel the pain?
• Does the pain feel dull, aching, or burning?
• Is it sharp, dull, throbbing, steady, other?
• How strong is the pain?
• How long does the pain last?
• What eases the pain?
• What makes the pain worse?
• What medicines are you taking for pain?
• How much relief are you getting from your medications?
• Describe how your pain affects your daily life. Does it stop you from working? Doing house hold chores? Seeing your friends and family? Going out and having fun?
• Talk about your goals for pain relief. Do you want no pain at all (which can sometimes be hard to achieve), or is your goal to feel well enough to do specific activities? (National Cancer Institute, 1999; National Cancer Institute, 2004b; National Cancer Institute, 2004c).

Keep a pain diary to try to assess the situation. A pain diary should include the date pain is felt, time of day, pain rating (from 0 to10), any pain medications taken (how often and how much), any side effects from medicines, other methods of pain relief tried (National Cancer Institute, 2004c).

Methods of Pain Relief: Medication and Non-medication Options

There are many methods of pain relief. Pain relief medications can be divided into three groups. The first group is for mild pain. You may have used some of these medications for past problems such as head or muscle aches, such as aspirin, ibuprofen, or acetaminophen.

The second group of medicines is for more severe pain. You may have heard them called narcotics or opiods (e.g., codeine, oxycodone, morphine, hydromorphone). Some patients are afraid to take opiods because they fear becoming addicted to them. This problem is extremely rare, occurring only in about 1 in 10,0000 patients. So don't let fear of addiction stop you from getting pain relief, as addiction is highly unlikely to occur. If you are worried about addiction, talk with your doctor.

Some patients also worry about taking strong medications too soon, fearing if pain gets worse there may be no options for pain management later. It is actually best to treat pain when it begins, even if strong medications are needed -- this will make it easier for doctors to control your pain later.

The third group of medicines is used to treat other medical problems. For example, medications such as antidepressants or seizure medications may be used to treat burning or tingling caused by nerve damage (National Cancer Institute, Understanding Cancer Pain, 2004c).

Most cancer medications can be taken orally in liquid or pill form. If medications cannot be taken by mouth, they can always be given in other methods (e.g., a patch, needle, suppository, or spinal tube).

There are also non-medication pain management methods that may be used successfully to treat cancer pain in conjunction with medications or by themselves. These may include the following:

• Physical therapy -- Going to a physical therapist may help relieve your pain. The therapist may use heat, cold, massage, pressure, and/or exercise to help you feel better.
• Braces -- These limit movement of a painful limb or joint.
• Acupuncture -- This is a proven method that uses needles at pressure points to reduce pain.
• Hypnosis, meditation, or yoga -- Any of these may help your pain. A trained specialist can teach you these approaches.
• Relaxation skills -- Many people with cancer have found that practicing deep relaxation helped relieve their pain or reduced their stress.
• Nerve blocks or surgery. If you do not get relief from the above approaches, you may want to ask the doctor about nerve blocks or surgical approaches to pain relief. Nerve blocks or surgery often help if you have persistent, limiting pain, but they may put you at risk for other problems. They may also require you to stay in the hospital (National Cancer Institute, 2004b).

When You Need Support: Putting Together a Health Care Team for Support

Coping with cancer is not easy -- for the patient or his/her loved ones. The important thing is to not try to "do it alone." In addition to the support of loved ones, support of a whole host of people is available through individual services and agencies. Developing a team of support persons and services starts with you -- the cancer patient and loved ones.

First consider these important tips when seeking support:

• When you are going to meet with someone (a doctor, nurse, or specialist), bring someone else with you. It helps to have another person hear what is said and think of questions to ask.
• Write out your questions beforehand to make sure you don't forget to discuss anything.
• Write down the answers you get, and make sure you understand what you are hearing.
• Do not be afraid to ask your questions or ask where you can find more information about what you are discussing. Being well-informed is your most important task as the central person on your health care team (National Cancer Institute, 2000b).

Next, consider who you want and need on your health care team. Your doctor will likely make recommendations. The following people can play a vital role in helping you obtain the best treatment possible and maintain the highest quality of life throughout your diagnosis and treatment (the following excerpts are taken from National Cancer Institute's "Your health care team: Your doctor is only the beginning," 2000b).

Social Workers: Lots of Help from One Place

Social workers are professionally trained in counseling and practical assistance. They provide the broadest range of help to people with cancer, and are a good place to start if you have recently been diagnosed with cancer and unsure of what to do next. Oncology social workers specialize in cancer; most hospitals that treat cancer patients have certified oncology social workers on staff. Clinical or psychiatric social workers have an advanced degree or Ph.D. in social work and are trained to provide family therapy, marital counseling, or counseling focused on coping with chronic illness. A hospital social worker can also refer you to a clinical social worker in private practice in the community.

The hospital social worker can also provide counseling, find a support group for you, locate services in your community that can help you with home care or transportation, and guide you through the process of applying to the government for Social Service Disability or other forms of assistance. They can also help you understand your diagnosis and talk to you about treatment, side effects, and what to expect. If you need help finding a social worker in your area, start by contacting your local hospital.

Psychiatrists: If You Need Medication or Feel Depressed

A psychiatrist is a medical doctor who specializes in providing psychotherapy, or general psychological help. A psychiatrist specializes in helping people who are depressed, anxious, or otherwise unable to cope psychologically. Because they are medical doctors, psychiatrists can also prescribe medication, such as antidepressants or medication to help you sleep. To find a psychiatrist, you can ask your doctor for a referral, ask if your hospital has a psychiatric department, call your Health Maintenance Organization (HMO) or other managed care plan, or ask a social worker to help.

Psychologists: Providing Therapy and Counseling

A psychologist is also someone who can assist you if you are feeling depressed, anxious, or sad. While not medical doctors, psychologists have obtained a doctoral degree in psychology and counseling; many specialize in marital counseling or chronic illness. Some cancer centers have psychologists on staff, but if you are looking for one, ask your doctor, your HMO, your hospital, or a social worker for a referral.

Nurses: A Very Important Role in Care

Nurses are an extremely important part of your health care team. Nurses have a wide range of skills, and are usually in charge of actually implementing the plan of care your doctor has set up for you. They are trained to administer medication and monitor side effects. All major medical centers have nurses who specialize in cancer. Whether you are staying in the hospital for care or receive it on an outpatient basis (which means you go home after each treatment), you will benefit from seeking assistance, asking questions, or getting tips and advice from your nurse or nurse-practitioner. Nurses are often aware of support services in your community and can usually provide you with educational materials and pamphlets.

You may also arrange or request a registered nurse to visit you at home if needed. If the visit is approved by your doctor, it will usually be covered by insurance. Another option is to hire a private duty nurse who does not work for your hospital or health care service. This can be expensive and often is not covered by insurance, but can ease the burden of care on your family or loved ones.

Home Health Aides: Care at Home

Another form of home care is from a home health aide. Home health aides assist people who are ill and need help moving around, bathing, cooking, or doing household chores. Some state Medicaid programs will pay for home health aide care, provided they are supervised by a nurse. However, private insurance or managed care plans rarely pay for a home health aide unless there is also a need for skilled nursing care. To find home health aide care, ask your physician, nurse, or social worker, and remember to ask if the charges vary based on income. Also, the National Association of Home Care (202–547–7424) publishes a free booklet, How to Select a Home Care Agency. The telephone yellow pages are another source, but be sure to check credentials, find out whether the agency is bonded, and ask for references.

Rehabilitation Specialists: Help for Recovery

Rehabilitation services help people recover from physical changes caused by cancer or cancer treatment. It includes the services of physical therapists, occupational therapists, counselors, speech therapists, and other professionals who help you physically recover from cancer. For example, physical therapy can help you rebuild the muscles in your arm and shoulder if you have had chest surgery.

Most physicians will refer you to rehabilitation services if you need them; be sure to ask if you think you might want them. Also, check to see if these types of services are covered under your insurance plan (some may be, others may not). Additionally, some cancer or social service organizations may provide you with free rehabilitation services if you are not insured for them.

Dietary or Nutritional Services

Cancer and cancer treatment can cause people to lose weight. For this reason, dietary or nutritional counseling or services are commonly prescribed for people with cancer. A dietitian can suggest ways to get enough calories, vitamins, and protein to help you feel better and control your weight, and can give you tips about increasing your appetite if you experience nausea, heartburn, or fatigue from your illness or treatment.

Most hospitals have registered dietitians on staff, and you can ask your doctor about meeting with them. If you are trying to locate a dietitian in your community, be sure to ask about experience and training. Remember to check if the services of a dietitian are covered under your insurance; if not, ask your doctor, nurse, or social worker about community-based programs that offer free services.

Clergy: Spiritual Support Is Important

Prayer and spiritual counseling can be very important in coping with a serious illness such as cancer. Many people find it useful to get help from clergy or other spiritual leaders, and there is no question that a strong sense of spirituality can help people face difficult challenges with courage and a sense of hope. Some studies show that people with cancer have less anxiety and depression, even pain, when they feel spiritually connected. Even if your beliefs are challenged by your illness, don't be afraid to reach out to others for help. It is important to remember that you are not alone at this time.

Hospice Care: Help with Terminal Illness

Hospice care focuses on the special needs of people who have terminal cancer. Sometimes called palliative care, this type of care focuses on providing comfort, controlling physical symptoms like pain, and giving emotional or spiritual support. Hospice care is usually provided at home, although there are hospice centers that operate much like hospitals and provide full-time care. Your doctor or social worker can refer you for hospice care.

Home hospice care is usually coordinated through a nurse, who then sends a home health aide, social worker, occupational therapist, clergy, or the type of specialist that is appropriate for the needs of the hospice patient. Hospice care is not for everyone. It is important to discuss this option carefully and get guidance from your doctor, nurse, or social worker.

Putting the Team Together: Find Help and Hope

A diagnosis of cancer may be the most difficult challenge you or your loved ones will ever face. That is why it is important to find help and try to maintain your sense of hope no matter what your situation. Your team of health care professionals is knowledgeable about the many different aspects of cancer: medical, physical, emotional, social, and spiritual. They are available to you as much or as little as you need, but it is difficult for them to know if you need help unless you ask for it. Don't be afraid, embarrassed, or hesitant to ask questions; voice your opinion, and seek the care you feel you need and deserve (National Cancer Institute, 2000b).

The Truth About Hospice Care Services: Dispelling the Myths

Many misconceptions exist about the services offered through hospice care. Here are some facts that can help dispel the myths about hospice care.

Hospice care is not a place where the terminally ill go to die; and, one does not have to be bedridden to use hospice care services. Hospice is actually a concept or philosophy of care and usually takes place in the home, although hospice centers are available around the country (Hospice Association of America, 2004).

Hospice care is for any person who has a life-threatening or terminal illness. Most reimbursement sources require a prognosis of six months or less if the illness runs its normal course (National Hospice and Palliative Care Organization, 2004). For medicare beneficiaries, if the patient lives beyond six months, he or she can continue to receive hospice services as long as a attending physician recertifies that the patient is terminally ill (Hospice Association of America, 2004).

Hospice serves both the person with cancer and their loved ones. Hospice also serves persons with other illnesses, including Alzheimer's, Parkinson's, meningitis, diseases of the respiratory system, etc. (Hospice Association of America, 2004).

Hospice care services are often thought to be very expensive because they offer 24-hour on-call services. Although they do offer these services, hospice care is, in fact, often less expensive than care in hospitals, nursing homes, or other institutional settings because in those types of facilities the patient is charged by the day. With hospice, the patient pays only for the services he or she or the family cannot provide and that are not covered by insurance (Hospice Association of America, 2004).

Hospice care is a family-centered approach that includes, at a minimum, a team of doctors, nurses, social workers, counselors, and trained volunteers. They work collaboratively focusing on the patient's needs, be they physical, psychological, or spiritual. The goal is to help keep the patient as pain-free and lucid as possible, with loved ones nearby until death (National Hospice and Palliative Care Organization, 2004).

Typically, a family member serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual. Members of the hospice staff make regular visits to assess the patient and provide additional care or other services. Hospice staff is on-call 24 hours a day, seven days a week (National Hospice and Palliative Care Organization, 2003).

The hospice team develops a care plan that meets each patient's individual needs for pain management and symptom control. The team usually consists of:

• The patient's personal physician;
• Hospice physician (or medical director);
• Nurses;
• Home health aides;
• Social workers;
• Clergy or other counselors;
• Trained volunteers; and
• Speech, physical, and occupational therapists, if needed (National Hospice and Palliative Care Organization, 2003).

Among its major responsibilities, the interdisciplinary hospice team:

• Manages the patient's pain and symptoms;
• Assists the patient with the emotional and psychosocial and spiritual aspects of dying;
• Provides needed drugs, medical supplies, and equipment;
• Coaches the family on how to care for the patient;
• Delivers special services like speech and physical therapy when needed;
• Makes short-term inpatient care available when pain or symptoms become too difficult to manage at home, or the caregiver needs respite time; and
• Provides bereavement care and counseling to surviving family and friends.

Below is a list of services available to Medicare hospice recipients:

• Physician services for the medical direction of the patient's care
• Regular home visits by registered nurses and licensed practical nurses
• Home health aides and homemakers for services such as dressing and bathing
• Social work and counseling
• Medical equipment such as hospital beds
• Medical supplies such as bandages and catheters
• Drugs for symptom control and pain relief
• Physical therapy, speech therapy, occupational therapy, and dietary counseling
• Volunteer support to assist patients and loved ones (National Hospice and Palliative Care Organization, 2004).

Because round-the-clock, hands-on care is the hallmark of the hospice experience, hospice provides trained volunteers to aid the family and patients. Most hospice volunteers are trained to relieve the primary caregivers, do household chores, and help bathe the patients. Perhaps the most important task, however, is their ability to be "good listeners" (National Hospice and Palliative Care Organization, 2004).

For more information about hospice care see the Hospice Association of America's "All About Hospice: A Consumer's Guide" (http://www.nahc.org/HAA/guide.html).

Support Services Contact Information: Finding Needed Services and Information

You may want more information for yourself, your family, and your doctor. The following is a list of contact information for service you may want to seek out.

The Cancer Information Service (CIS) line from the National Cancer Institute (NCI) is a good place to start. CIS provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment. Toll-free: 1-800-4-CANCER (1-800-422-6237) or TTY: 1-800-332-8615.

NCI Online: http://www.cancer.gov/ to reach NCI's Web site.

"LiveHelp" Cancer Information Specialists offer online assistance through the LiveHelp link on the NCI's Web site.

American Dietetic Association's Consumer Hotline: 1-800-366-1655.

Texas Resources

American Cancer Society - Texas Division
Address: 2433 Ridgepoint Dr. #B
Austin, TX 78754
USA Phone: (512) 919-1800
(800) ACS-2345
Fax: (512) 919-1846
Website: http://www.cancer.org/

Arlington Cancer Center
Address: 906 West Randol Mill Road
Arlington, TX 76012
USA Phone: (817) 261-4906
1-800-344-8351
Fax: (817) 261-5837
Email: accnurse@acctx.com
Website: http://www.acctx.com/main.htm

Cancer Care of Houston, Inc.
Address: 9575 Katy Freeway, Suite 428
Houston, TX 77024
USA Phone: (713) 461-0028
Fax: (713) 461-0704
Email: info@cancare.org
Website: http://www.cancare.org/

Cancer Counseling, Inc.
Address: 4101 Greenbriar #317
Houston, TX 77098
USA Phone: (713) 520-9873
Fax: (713) 520-9288
Email: cancercounseling@hotmail.com
Website: http://www.cancerhouston.com/

Catholic Charities - Texas
Address: See website for listings in Amarillo, Austin, Beaumont, Corpus Christi, Dallas,
El Paso, Galveston, Ft. Worth, Houston, Lubbock, Odessa, San Juan, Victoria, TX USA
Web Site: http://www.catholiccharities-md.org/

Children's Health Insurance Program (CHIP) - Texas
Address: Department of Health and Social Services
PO Box 13247
Austin, TX 78711
USA Phone: (512) 424-6536
(800) 735-2988 TDD
(800) 647-6558
Website: http://www.texcarepartnership.com/

Dallas Self-Help Clearinghouse
Address: c/o Mental Health Association of Greater Dallas
624 N. Good-Latimer Expwy., Suite 200
Dallas, TX 75204
USA Phone: (214) 871-2420
Fax: (214) 954-0611
Email: Tsimmons@MhaDallas.org
Website: http://www.mhadallas.org/

Houston Area Self-Help Clearinghouse - Harris County
Address: Mental Health Association in Houston and Harris County
2211 Norfolk #810
Houston, TX 77098
USA Phone: (713) 522-8963

Jewish Family Service
Address: Jewish Family Service of Colorado
Denver, CO 80222
USA Phone: (303) 759.4890
Fax: (303) 759.5998
Email: jfs@jewishfamilyservice.org
Website: http://www.jewishfamilyservice.org/

Leukemia and Lymphoma Society - North Texas Chapter
Address: 12850 Spurling Drive, Suite 220
Dallas, TX 75230
USA Phone: (972) 239-0959
(800) 800-6702
(800) 955-4572
Fax: (972) 239-0892
Email: infocenter@leukemia-lymphoma.org
ntlsa@altinet.net
Website: http://www.leukemia.org/hm_lls

Life After Cancer Care (LACC)
Address: The University of Texas M. D. Anderson Cancer Center
1515 Holcombe Boulevard
Houston, TX 77030
USA Phone: (713) 792-6161
(800) 392-1611
Website: http://www.mdanderson.org/

LIHEAP Assistance for Texas
Address: Texas Department of Health and Social Services
Division of Public Health, PO Box 13941
Austin, TX 78711-3941
USA Phone: (512) 475-3864
Fax: (512) 475-3935
Website: http://www.tdhca.state.tx.us/

Maddox Shop
Address: 130 Casa Linda Plaza
Dallas, TX 75218
USA Phone: (214) 328-3009
(888) 225-2119
Fax: (214) 328-2132
Website: http://www.maddoxshop.com/

San Antonio Cancer Institute
Address: Urschel Tower, 5th Floor
7979 Wurzbach Road
San Antonio, TX 78229
USA Phone: (210) 616-5590
Fax: (210) 616-5981
Website: http://www.ccc.saci.org/

San Antonio Self-Help Clearinghouse
Address: Mental Health Association in Greater San Antonio
901 NE Loop 410, #504
San Antonio, TX 78209
USA Phone: (210) 826-2288

Second Silhouette
Address: 1724B Sunset Blvd.
Houston, TX 77005
USA Phone: (713) 529-3733
Fax: (713) 529-8453
Email: secondsil@msn.com

Sisters Network - Houston Chapter
Address: P.O. Box 710350
#341
Houston, TX 77271
USA Phone: (281) 261-1290
(713) 794-6576
Fax: (713) 261-2809
Email: Jwork53827@aol.com, j_workcuff@hotmail.com
Website: http://www.sistersnetworkinc.org/

Sisters Network, Inc. - Austin Chapter
Address: 6810 Colony Park
Austin, TX 78724
USA Phone: (512) 926-3708
Fax: (512) 926-0765
Website: http://www.sistersnetworkinc.org/

Sisters Network, Inc. - Dallas, Texas Chapter
Address: 1610 Brandy Lane
Allen, TX 76002
USA Phone: (214) 879-2148
(972) 442-5104
Fax: (410) 879-2681
Website: http://www.sistersnetworkinc.org/

Sisters Network, Inc. - North Texas Chapter
Address: 2318 Overland Lane
Arlington, TX 76014
USA Phone: (817) 461-5525
(817) 534-0814 x2349
Fax: (817) 535-6280
Email: dblakney@ccdofw.org
Web Site: http://www.sistersnetworkinc.org/

Tarrant County Cancer Care Services
Address: Cancer Care Services
623 South Henderson
Fort Worth, TX 76104
USA Phone: (817) 921-0653
Fax: (817) 921-1701
Website: http://www.cancercareservices.org/

Texas Breast and Cervical Cancer Control Program
Address: Texas Department of Health
1100 West 49th Street
Austin, TX 78756
Website: http://www.tdh.state.tx.us/

Texas Cancer Council
Address: P.O. Box 12097
Austin, TX 78711
USA Phone: (512) 463-3190
Fax: (512) 475-2563
Website: http://www.texascancercouncil.org/

Texas Cancer Data Center
Address: Texas Cancer Data Center - 573
1515 Holcombe Blvd.
Houston, TX 77030-4009
USA Phone: (713) 792-2277
Fax: (713) 794-1951
Email: tcdc@txcancer.org
Web Site: http://tcdc.uth.tmc.edu/

Texas Department of Health
Address: 1100 West 49th Street
Austin, TX 78756
USA Phone: (512) 458-7519
(512) 458-7111
Fax: (512) 458-7467
Website: http://www.tdh.state.tx.us/

Texas Department of Human Services
Address: John H. Winters Human Services Complex
PO Box 149030
Austin, TX 78714-9030
USA Phone: (512) 438-3011
Website: http://www.state.tx.us/

Texas Health Insurance Risk Pool
Phone: (888) 398-3927

Texas Medicaid Agency
USA Phone: (512) 424-6500
(800) 252-8263
Email: medicaid@hhsc.state.tx.us.
Website: http://www.hhsc.state.tx.us/

Texas Self-Help Clearinghouse
Address: c/o Mental Health Association in Texas
8401 Shoal Creek Blvd
Austin, TX 78757
USA Phone: (512) 454-3706
Fax: (512) 454-3725
Email: mhainfo@mhatexas.org
Website: http://www.mhatexas.org/

The Surrey House
Address: 8330 South Main
Houston, TX 77025
USA Phone: (281) 667-9261
1-800-800-9261

University of Texas M.D. Anderson Cancer Center
Address: 1515 Holcombe Boulevard
Houston, TX 77030
USA Phone: (713) 792-6161
(800) 392-1611
Web Site: http://www.mdanderson.org/

Women's Health Boutique
Address: 12715 Telge Road
Cypress, TX 77429
USA Phone: (281) 256-4100
(888) 280-2053
Fax: (281) 373-4450
Email: w-h-b@w-h-b.com
Web Site: http://www.w-h-b.com/

For descriptions of each of these Texas services see http://www.cancercare.org/HelpingHandsGuide/.

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References

• American Society of Radiologic Technologists (2000). Planning radiation treatment [on-line]. Available: https://www.asrt.org/media/pdf/RadTreatPlan_Eng_v2.pdf.
• American Cancer Society (2004a). Common questions about diet and cancer [on-line].
  Available: http://www.cancer.org/docroot/PED/content/
  PED_3_2X_Common_Questions_About_Diet_and_Cancer.asp
• American Cancer Society (2004b). Does chemotherapy hurt? [on-line].
  Available: http://www.cancer.org/docroot/ETO/
  content/ETO_1_7X_Does_Chemotherapy_Hurt.asp.
• American Cancer Society (2004c). Other general health concerns [on-line].
  Available: http://www.cancer.org/docroot/ETO/
  content/ETO_1_4X_Other_general_health_
  concerns.asp?sitearea=ETO.
• Hospice Association of America (2004). Fact or fiction: Learning the truth about hospice [on-line]. Available: http://www.nahc.org/HAA/fact_fiction.html.
• National Cancer Institute (1999). Chemotherapy and you: A guide to self-help during cancer treatment [on-line]. Available: http://www.cancer.gov/cancertopics/chemotherapy-and-you.
• National Cancer Institute (2004a). Eating hints for cancer patients: Before, during, and after treatment [on-line]. Available: http://www.cancer.gov/cancertopics/eatinghints.
• National Cancer Institute (2004b). Facing forward series: Life after cancer [on-line]. Available: http://www.cancer.gov/cancerinfo/life-after-treatment.
• National Cancer Institute (2000a). Pain control: A guide for people with cancer and their families [on-line]. Available: http://www.cancer.gov/cancertopics/paincontrol.
• National Cancer Institute (2004c). Understanding cancer pain [on-line]. Available: http://www.cancer.gov/cancertopics/understanding-cancer-pain.
• National Cancer Institute (2000b). Your health care team: Your doctor is only the beginning [on-line]. Available: http://cis.nci.nih.gov/fact/8_10.htm.
• National Hospice & Palliative Care Organization (2004). Six frequently asked questions [on-line]. Available: http://www.nhpco.org/i4a/pages/index.cfm?pageid=3306.
• National Hospice & Palliative Care Organization (2003). What is hospice and palliative care? [on-line]. Available: http://www.nhpco.org/i4a/pages/index.cfm? pageid=3281&openpage=3281.
• The Cancer Council Victoria (2004a). A balanced diet [on-line]. Available: http://www.cancervic.org.au/cancer1/patients/eating/baldiet.htm.
• The Cancer Council Victoria (2004b). Cancer and food [on-line]. Available: http://www.cancervic.org.au/cancer1/patients/eating/foods.htm.
• The Cancer Council Victoria (2004c). Weight problems [on-line]. Available: http://www.cancervic.org.au/cancer1/patients/eating/weight.htm

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Last updated: 6 January, 2008

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