Info Centre - Reports

Frequently Asked Questions
Articles
Reports
Useful Links
Book Review
Clipping File
Cancer Brochures
Chat Transcripts

Reports

Monthly Report, March 2002

Monthly Report, March 2002

Main Stories

Breast Cancer Support Group Volunteers' Training Programme.

Department Reports

Cancer Awareness Programme

Prevention and Early Detection

Insurance

Patient Care

At Smt. Panadevi Dalmia Cancer Management Centre
At Tata Memorial Hospital
"Can I Help You?" CPAA’s Desk at Tata Memorial Hospital’s Private OPD
At Bai Jerbai Wadia Hospital for Children
Palliative Care Unit at Tata Memorial Hospital
Counseling at Tata Memorial Hospital’s Radiation Treatment Centre
Counseling of Breast Cancer Patients at Tata Memorial Hospital
Counseling at Cama & Albless Hospital Cancer Ward
Nair Hospital (Radiation Department)

Rehabilitation

Breast Cancer Support Group Volunteers' Training Programme

Last month a report of the medical aspects of breast cancer support were covered in our Monthly Report. This month we cover Lymphedema Management, Diet and Palliative Care. The programme was organised by Indian Cancer Society (ICS) and Sahachari-Mastectomees Association, India from 18th to 21st February 2002.

Dr. Anita Patil of Tata Memorial Hospital covered the topic of lymphedema management in breast cancer. In the 30s, a Halsted total radical mastectomy was the prevalent treatment given for breast cancer. This would often result in swelling of the arm, lymphedema. The lymphatic system consists of fine vessels carrying a colourless fluid called lymph, interspersed with grape sized nodes which act as filters for disease causing germs in our bodies. There is an especially rich supply to the breast. These further drain into the deep lymphatics and finally into a vein. During surgery for breast cancer when axillary nodes are removed for diagnostic purposes, these connections are disturbed. Even today there is some incidence of acute, late acute and chronic inflammatory lymphedema (development of redness due to infection), which must be referred to the treating doctor. Dr. Patil's talk covered a specific form of lymphedema, which sometimes develops in the arm on the same side of the operation for breast cancer, which can be managed. To determine whether there is lymphedema, the diameter of the arm on either side is measured at two points between each of two joints (fingers, wrist, elbow and shoulder). A difference of up to 2 cm indicates a mild condition; 2-5 cm a moderate condition and more than 5 cm indicates a severe condition of lymphedema.

Patients must be told about the importance of preventing lymphedema. They should not take injections, intravenous fluids on the affected arm. Blood pressure measurement should be done on the other arm. Cuts, bruises should be avoided. The patient should always carry an antiseptic kit and mosquito repellant. Hair removal should be done using creams, never by shaving or waxing. Whenever possible finger caps should be used to protect the finger tips from abrasion. Patients are told about exercises, which must be performed regularly for their whole life. Under no circumstance should swelling be treated with fomentation, hot water bottles or bath. In earlier days, not much could be done to reverse lymphedema, but Dr. Patil has had some measure of success in treating patients by superficial and deep massage, pressure bandage and sleeves, pneumatic pressure pump, positioning and exercises.

Mona Mukadam of Hinduja Hospital presented an extremely useful talk on "Diet and Nutrition for Cancer Patients". Diet plays an important part in improving the ability of the patient to cope with treatment even at higher doses. It is important to include carbohydrates (bread, rice), proteins (meat, poultry, dal), fats (oil and butter) and vitamins and fibre (fruits and vegetables) in the diet. A typical daily diet should include 4 servings of cereals (1 bowl of rice/ 2 chapattis/ 1 slice of bread, nachani, jawar or bajra), 3 servings of proteins (2 oz meat/ 1 bowl whole dals), 2 servings of oil, 2 cups of milk and 4 servings of fruits and vegetables (1 bowl of vegetables, half a banana, 1 orange). In general there are no restrictions to what a patient can eat, but you should aim for a diet high in proteins and calorific value. It is important to have small and frequent meals to ensure that the total intake is not reduced.

During treatment patients experience a loss of appetite and a change in taste. Try to coax the patient's palate by changes in diet and including different items. Take advantage of days when there is an improvement in appetite. If the patient themselves are cooking, cook when you can and freeze the food to be eaten later. It has been observed that building a positive ambience, for example by mixing colours can help improve appetite. A change in scene, even another room in the house can make a difference. Some advice to patients-Avoid drinking liquids before and during meals unless absolutely necessary and then have milk instead of water. Always eat with your family. If you experience a feeling of fullness, have small but frequent meals, eat slowly, chew your food well and savour every bite. Avoid salads and clear soups which have no calories or add cheese, mayonnaise, curd dressings and cream to enhance the nutritional value. Some patients find drinking colas, jal jeera, limejuice or having mild pickles and lemon helpful. Food should be served at room temperature. Sometimes the smell of cooking such as fish or deep-frying can bring on nausea. In case these general measures do not relieve nausea, medicines can be taken 30-45 minutes before a meal. A patient should be told he is taking nausea controlling medication. This helps relieve symptoms psychologically. Dry food first thing in the morning like toast or biscuits have been found to be beneficial. Avoid eating just before treatment. Distract yourself by reading books or watching TV.

Typical eating problems that are encountered are sore mouth, dry mouth, change in taste, constipation, diarrhoea, flatulence, nausea and reduced appetite.

Patients often experience a sore mouth due to chemotherapy or improper flow of saliva. For a sore mouth, avoid citrus juices. Have khichadi, bananas, soft paneer, fresh curd (not sour). Avoid hard foods and break into small pieces. Use a straw when possible. Sucking on sweets, wetting food by dipping in dal or milk helps. Try pureeing food in a blender. Drinking the Hamdard drink, Rooh Afza in cold milk, has helped many patients to overcome a sore mouth.

In case of diarrhoea drink plenty of fluids, rice kanji, noodles, boiled egg whites, bread, whey, arrow root and soups. Avoid food with high amounts of fibre like cauliflower and cabbage. To restore the sodium/potassium balance, the patient should be given Electral, banana, apple and potato. Avoid milk, but have buttermilk, curds which have the lactose in a broken down form, which is easier to digest.

For constipation, increase the fibre content in your diet. Drink plenty of fluids through the day and a glass of hot water and honey just before bowel movement. Eat a lot of vegetables, blenderise if desired, but do not strain.

Dried ginger or ginger soaked in lemon juice or ajwain water can be taken to relieve flatulence. To prevent gas, avoid sprouted pulses, otherwise they are a healthy source of proteins.

There are many commercially available formulas to boost nutrition. Some commonly used for cancer patients are Resource, Nutrocal, Glucema, Nutren, Ensure and Impact. A special feed can also be made at home. Add 50g wheat flour to 60ml oil or ghee and cook, then add 60g soya flour and cook further. Remove from the heat and add 25g moong dal, 100g carrot and 100g jaggery. Pressure cook this mixture and blend with a little water. The feed can be stored in the fridge and used whenever needed by diluting with water or mixing with dal or khichadi. For diabetics, leave out the jaggery.

To increase nutritional value of any meal, add skim milk powder to curd, custard, desserts, soup, milk and gravies. Once opened a skim milk packet must be stored in a tightly closed container. Add roasted and powdered nuts, chana dal or peanuts to porridge, shira, halwa. Add vegetables, paneer or moong dal to parathas. Mix moong dal and soya flour in the normal wheat flour. Boil milk to ¼ or ½. Milk in the form of basundi, rabri and kheer is also a good form of nutrition. Add commercial supplements to ice cream and refreeze. Chicken stock and boiled chicken can be cooked ahead of time and kept in the freezer so that they are readily available when the patient feels hungry. Whenever the patient has juices, add glucose. Add vegetables, cheese and chana dal to snacks. For a cheaper alternative, have til, groundnuts, jaggery, grated coconut. Instead of plain rice, give a khichadi with dals and vegetables and cooked with excess water (3-4 times instead of 2). Flour of equal amounts of nachani, moong dal and lapsi (broken wheat) can be made by roasting each individually and grinding. A tasty porridge can be made of this flour in a pressure cooker by adding milk, cardamom and saffron. In general, coloured foods and especially yellow foods have been shown to have anti-cancer properties. Vitamin A, E, K and selenium should be included in the form of supplements.

Dr. Z Baretto, who has worked at the hospice, Shanti Avedana Ashram since 1986, covered the difficult topic of Palliative care. When the point is reached where curative treatment is not possible, there is still the option of control of symptoms and pain to allow the patient a measure of comfort. At this stage, both physical and emotional problems need to be tackled. No one is ever fully ready to die and patients need help to allow them to live with dignity until the final day. Today the phrases "Terminally Ill" have been replaced by "Advanced Cancer", "Palliative Care" by "Alternative care".

On admission, the typical symptoms encountered are pain, sleeplessness and disturbed bowel movement. The aim is not only to provide freedom from pain and fear but freedom from the memory of pain. Drugs are given "by the ladder", starting with aspirin, brufen, combiflam, codeine and morphine. Medication by mouth has been found to be better than injections which are given only in emergencies to control breakthrough pain. Dosage is gradually increased where necessary but is never given more frequently than 4 hourly. Medicines are given by the clock to allow round the clock pain control rather than waiting for pain to start. Medication cannot be combined since different drugs are often fighting for the same receptor.

The motto at Shanti Avedana Ashram is to "Add life to days rather than days to life." No saline, blood or oxygen is given to inmates. Pain can also be mental, psychological, spiritual, social and financial and each facet must be addressed. The patient generally goes through the entire progression of emotions from anger, denial, bargaining and depression until they finally reach acceptance.

The hospice promises to relieve the suffering and helps to share the family's burden. This allows a time to plan for the future, fulfilling of wishes and resolving of unfinished business. Proper communication is necessary to build trust and increase compliance. Conveying the proper information leads to a reduction in uncertainty, and can be an analgesic in itself. Every patient has a right to know as much as they want to know about what the future holds for them. They should be explained the prognosis in a manner so that they can accept the imminent, in small doses, emphasizing the positive aspects. "Always speak the truth but the sweet truth, not necessarily the bitter truth." The proper time should be chosen when the patient is comfortable and pain free. The hospice also believes in bereavement counseling for the family to help them to cope. At this stage, communication is stunted as individuals try avoidance. There is a lack of emotional energy, feelings of fear, guilt, for example, at not having done all that could have been done. Anticipated death is far worse than sudden death. Guidance must be given to cope with grief and to help voice it. Shanti Avedana has the facility of "Day Hospice" to allow a period of relief for families and access to doctors and basic nursing care, psychological support, mental and social stimulation for the patient. The hospice which has branches in Mumbai, Goa and Delhi, provides Home care through by a caring professional team.