Transcript for: Introduction to Chemotherapy: A Presentation for Patients and Families (North East Cancer Centre)
welcome to an introduction to chemotherapy a presentation for patients
and families in this presentation we will review what chemotherapy is side
effects of chemotherapy treatment how to manage these side-effects which symptoms to report to your cancer care team how
to report them and what supportive care and pharmacy services are available to you firstly we will review what cancer
is cancer is a disease that starts in the cells of our body normally our
body's cells grow in an orderly fashion but sometimes the information gets mixed up causing the cells to behave and grow
abnormally these abnormal cells can then develop into lumps or tumors which can
spread to other parts of the body cancer is named after the part of the body where it started for example breast or
prostate now we will discuss chemotherapy and how it works to fight
cancer also called chemo it is a way to treat cancer that uses drugs to kill
cancer cells there are over 100 different kinds of chemotherapy drugs that can be used some patients may be
given more than one kind of chemotherapy drug to treat their cancer chemotherapy
may be used to shrink a tumor before radiation therapy or surgery destroy any
remaining cancer cells after surgery or radiation therapy make other therapies
more effective or destroy cancer cells that return or spread to other parts of
your body chemotherapy can be given by intravenous infusion taken in pill form
given by an injection into fatty tissue or through an infusion pump over a few
hours or days you may have chemotherapy in cycles which means a period of
treatment and then a period of rest for example a four-week cycle maybe one week
of treatment and three weeks of rest the rest allows your body to make new healthy cells
chemotherapy treatment may cause side-effects chemotherapy target cells that grow and divide quickly as cancer
cells do chemotherapy worked throughout your body so it can also affect some fast-growing healthy cells like those of
the skin hair intestines and blood this is what causes some of the side effects
from the treatment the specific side effects related to your particular drugs will be discussed with you by your
cancer care team you will not experience all side effects and some side effects
can be prevented your oncologist will monitor your blood cell counts carefully
during your treatment as chemotherapy can lower this low blood cell counts can
put you at risk of serious complications which we will discuss on the next few slides blood values must return to a
safe level prior to each chemotherapy treatment blood test results may affect
treatment it is not unusual for your treatment to be delayed up to one week
if your blood cells are too low blood tests are to be done before noon the day
before your treatment or in the morning on the day of treatment on Mondays or
after statutory holidays the lab at the Cancer Center opens at 7 a.m. we ask
that you register at the chemo registration desk three hours before your appointment if blood work is
required on the same day of treatment or 15 minutes before your appointment if
blood work is not required the same day as treatment when checking your blood
cell count your oncologist is looking at the following white blood cells which
help your body fight infection a low white blood cell count leaves your body
more open to infection and if an infection does develop your body may be
unable to fight it off platelets which help your blood to clot a low platelet
count means your body may not be able to stop itself from bleeding and lastly red
blood cells which carry oxygen throughout your body your red blood cells ability to carry oxygen is
measured by the amount of hemoglobin in your blood if your level of hemoglobin is low you're anemic and
your body works much harder to supply oxygen to your tissues this can make you
feel fatigued and short of breath blood cell levels may decrease following chemotherapy but they are expected to
return to normal levels by the start of your next scheduled treatment a low
white blood cell count known as neutropenia puts you at a higher risk of developing an infection white blood
cells are your infection fighting cells and they may be lowered for a short period of time after receiving your
chemotherapy treatment if you develop an infection when you have a low white blood cell count your body may not be
able to protect itself and fight the infection infection can lead to death in severe cases therefore it is important
to recognize the signs and symptoms of an infection signs and symptoms of
infection include fever flu-like symptoms such as body aches feeling warm
chilled or shaky sore throat or mouth productive cough or shortness of breath
burning when urinating or urinating more often areas of redness or tenderness and
loose or liquid stools it is very important to report any of these signs
and symptoms to your cancer care team immediately things you can do to prevent
infection include wash your hands frequently with soap and water before eating and preparing food and after
using the bathroom or sneezing avoid people with infections such as people
who are coughing have a runny nose or flu-like symptoms avoid children who have the chickenpox
or measles or adults who have shingles the flu vaccine is recommended during
flu season talk to your oncologist before getting a vaccination check with your oncologist before having
any invasive procedures such as dental or surgical work good oral care is
essential so brush your teeth with a soft toothbrush after eating and before bedtime carry a small bottle of hand
sanitizer with you as an alternative to soap and water avoid handling pet feces
including fish tanks avoid skin cuts and Nick's and again remember to wash your
hands while these strategies will not raise your white blood cell count they will help to avoid infection a fever is
a temperature of 38.3 degrees Celsius or 100 point 9 degrees Fahrenheit or
higher at any time or 38 degrees Celsius which is a 100 point 4 degrees
Fahrenheit or higher for at least one hour a fever is a sign of infection even
if you do not have any other signs a fever is serious when your white blood cells are low
do not take medications to lower your fever such as Tylenol or acetaminophen
unless directed by your cancer care team we recommend that you take your
temperature anytime you have signs or symptoms of infection such as chills sweats sore throat or if you are feeling
unwell before taking Tylenol or acetaminophen for pain and on a daily
basis remember that a normal temperature is 37 degrees Celsius which is 98.6
degrees Fahrenheit and a fever is 38.3 degrees Celsius or higher at any time or
38 degrees Celsius or higher for at least one hour it is important to know
how to take your temperature properly so you get accurate results oral thermometers are recommended to use do
not eat drink smoke or put anything hot or cold in your mouth 20 minutes before you take your
temperature turn your thermometer on by pushing the on button place the
thermometer under your tongue into a side pocket close your mouth wait for the beep to indicate your
temperature has been read read and record your temperature if you have a
fever follow these guidelines do not take medications such as Tylenol or
acetaminophen to reduce your fever go immediately to the closest hospital emergency room
tell the emergency room staff that you are on chemotherapy and you have a fever
you will need blood work drawn and may need antibiotics let your primary nurse
and oncologist know of any visit you have had to the emergency room or hospital why you were there and what
treatment you received if any as previously mentioned platelets are responsible for making
clots chemotherapy can lower your platelet count and affect your body's ability to form clots this can put you
at risk for bleeding so it is important to be able to recognize the signs and symptoms of low platelets a low platelet
count can delay your treatment you may have to wait until your platelet levels go up in order to continue with
chemotherapy signs and symptoms of low platelets include the following cuts
that won't stop bleeding bruises on the body bleeding from the nose or gums a
red pinpoint rash black tari stools and blood in your urine it is important that
you report any signs and symptoms of low platelets to your cancer care team the
following are some strategies to manage low platelets and reduce your risk of bleeding use a soft toothbrush when
brushing your teeth continue regular oral hygiene and use caution when flossing use an electric razor to shave
blow your nose gently prevent constipation avoid ibuprofen also known
as Advil and aspirin also known as a si unless ordered by your doctor and avoid
high-risk activities such as contact sports red blood cells deliver oxygen
throughout your body chemotherapy can lower your red blood cell count and lower your energy level a low red blood
cell count is known as anemia it is important to be able to recognize the
signs and symptoms of low red blood cells signs and symptoms of low red
blood cells or anemia include a lack of energy fatigue a pale appearance
shortness of breath and chest tightness or chest pain it is important to report
any signs and symptoms to your cancer care team the following are some
strategies to manage low red blood cells or anemia get plenty of rest aim for at
least eight hours a night take short naps during the day if needed eat well food high in iron such as red
meat or leafy greens are good choices anemia can be relieved with a blood
transfusion or with medication to increase your body's production of red blood cells so be sure to talk to your
cancer care team about your symptoms if you are experiencing chest tightness or
chest pain go immediately to the closest hospital emergency room cancer related
fatigue is the most common symptom during and after chemotherapy treatment it is different than fatigue you felt
before you had cancer it is a feeling of tiredness that can last a long time and does not go away with rest or sleep it
can affect your emotions relationships and other parts of your life it can make carrying out regular daily activities
very hard it is often overlooked but is real and can be managed
research shows that exercise is the best way to improve your energy and make your
fatigue better aim to get 30 minutes of moderate exercise on most days the
activity shouldn't be too easy or too hard you should be able to talk comfortably while you are exercising
having cancer is stressful and emotional research shows that talking to someone
about your feelings or doing activities such as yoga or meditating to relieve stress and
anxiety can help your fatigue eat healthy foods and lots of variety to
have more energy to stay hydrated drink at least six to eight glasses of water
or other liquids every day when you are fatigued you may have less energy for
daily activities use your energy wisely in order to be able to do the things
that are most important to you listen to your body and rest when needed it is
common for people with cancer to have problems sleeping but you can make small changes to get better rest wake up at
the same time each day during the daytime rest in a room other than your bedroom limit alcohol and caffeine in
the afternoon and evening turn off all screens including computers TVs and
iPads at least one hour before going to bed you don't have to cope with your
fatigue alone allow family and friends to help you there are many places to
find support in your community and through your cancer care team the North East Cancer Center offers a fighting
cancer related fatigue class led by the supportive care program for cancer patients and caregivers the class offers
strategies for coping with fatigue and is available by teleconference Cancer
Care Ontario also has a patient symptom management guide called how to manage your fatigue that can be used by
patients and families other possible side effects of chemotherapy are nausea
and vomiting nausea is an unpleasant queasy feeling or feeling sick to your
stomach vomiting is throwing up not all people receiving chemotherapy experience
nausea and vomiting your oncologist will give you a prescription to help prevent
nausea and vomiting you can fill your prescriptions at the northeast Cancer Center outpatient pharmacy or at your
local community pharmacy bring the medications with you to your chemotherapy appointment
less advice do not take these pills prior to coming to your chemotherapy appointment these prescriptions can be
costly let your cancer care team know if you need help financially strategies to
help manage your nausea and vomiting include staying hydrated by drinking 68
cups of fluid a day or by sucking on ice chips eating frequent small light meals
and keeping your mouth clean by brushing your teeth at least twice daily it is
recommended to avoid hot spicy greasy foods heavy meals immediately after your
chemotherapy treatment and strong smells Cancer Care Ontario has developed a
patient symptom management guide called how to manage your nausea and vomiting that can be used by patients and family
contact your cancer care team for nausea lasting longer than 24 hours
constipation is when you are having bowel movements less often than normal and it is often dry and hard to pass
constipation can be caused by some chemotherapy medications some
anti-nausea medications most pain medications reduced fluid or fiber
intake stress anxiety depression or a lack of exercise strategies to manage
constipation include increasing your fluid intake by drinking 6 to 8 cups of
fluid per day increasing your fiber intake being as physically active as
possible using laxatives such as Senna cot or lactulose and following a
bathroom routine it is normal to have a bowel movement every two to three days even when little food is eaten
do not use suppositories enemas or take fiber supplements if you have not had a
bowel movement in three days talk to your cancer care team Cancer Care Ontario has a symptom management
guide called how to manage your constipation that can be used by patients and
Emily diarrhea is loose watery or unformed stool that happens more than
three or four times a day and can be serious if not managed diarrhea can be
caused by chemotherapy drugs antibiotics and laxatives stress and anxiety
infection radiation to the pelvic area or bowel surgery strategies to manage
diarrhea include taking anti diarrheal medication if prescribed by your
oncologist drinking at least six to eight cups of fluid per day eating small
frequent meals planning your outings and taking care of your skin it is
recommended to avoid spicy greasy high-fiber foods and artificial
sweeteners for diarrhea lasting more than 24 hours contact your Cancer Care Team Cancer
Care Ontario has a patient symptom management guide called how to manage your diarrhea that can be used by
patients and family mouths problems is a common side effect of chemotherapy
within a few days after treatment you may experience dry mouth and lips
cankers and cold sores too much or sticky saliva taste changes trouble or
pain with swallowing tooth and gum problems stiff jaw bad breath burning
mouth or feeling thirsty all the time strategies to prevent and manage mouth
problems while on chemotherapy include seeing a dentist before you start your
treatment whether you have your own teeth or dentures the Cancer Center has
a dental oncology team who provide care for patients with cancer before chemotherapy treatment patients may self
register to the dental oncology program or ask their cancer care team to make a
referral on their behalf keeping your mouth and lips moist brushing with a
soft toothbrush flossing gently rinsing your mouth four to five times a
day with a baking soda salt rinse and quitting smoking it is recommended to
avoid mouthwash containing alcohol and petroleum-based lip balm wearing
dentures that did not fit well eating spicy acidic hot and dry food
that have sharp edges and caffeine and alcohol it is important to report the
following mouth problems to your cancer care team fever strong pain in your
mouth or jaw swelling numbness heaviness in the jaw trouble swallowing a choking
feeling and white patches or red and swollen patches in your mouth Cancer
Care Ontario has a patient symptom management guide called how to manage your mouth problems that can be used by
patients and family the Cancer Center also has a patient handout called how to
care for your mouth during active chemotherapy that includes a recipe for a preventative mouth rinse now let's
discuss why you should quit smoking after a cancer diagnosis it has been
shown that smoking during cancer treatment can lead to worse treatment side effects poor healing and decreased
response to treatment it has also been shown that smoking after cancer treatment can lead to a higher risk of
recurrence of cancer increased risk of developing second cancers and decreased
life expectancy the North East Cancer Center clinical tobacco services program
which is part of the dental oncology clinic want to help you quit smoking and they can provide counseling services
medication and nicotine replacement therapy ask your cancer care team for a
referral alternatively patients may self refer to the program
let's talk about hair loss and Sun safety some chemotherapy drugs can cause
hair loss hair loss can begin two to three weeks after your first treatment
your scalp might feel tender when the hair starts to fall out your hair will
begin to grow back three to four weeks after your last treatment the color and texture of your hair may be different
volunteers in the chemotherapy room will show you hats or turbans if you would
like to have one or two they are free of charge while you're on chemotherapy your
skin may be more sensitive to the Sun so it is recommended to wear a hat use
sunscreen and stay in the shade the following are some resources for hair
loss your oncologist can provide you with the prescription for a week as some
insurance plans cover this cost we recommend you visit a week shop before you lose your hair so you can match your
hair color and style donated weeks are available free of charge at the daffodil
Terrace Lodge head coverings are available free of charge in the chemo therapy room the Cancer Center offers a
look good feel better program for women this beauty workshop provides women with
the tools and techniques to feel beautiful and vital restore a sense of self and renew a feeling of womanhood
the workshop shows women steps they can take so they can look good feel better and get closer to the person they were
before they began their cancer journey for more information or to register for
a class contact the daffodil lodge on this slide we will discuss memory
changes sometimes referred to as chemo brain or chemo fog that may occur during
cancer treatment some memory changes that patients may experience include
difficulty with concentration thinking and focusing changes in your memory and
concentration may be subtle or they may be quite bothersome these side-effects
may disappear after your treatment is completed this may also be caused by chemotherapy
fatigue stress or insomnia strategies to manage memory changes include planning
activities ahead of time making lists to facilitate recall and asking for help
whether it be from family and friends or the supportive care team at the Cancer Center chemotherapy treatment may cause
changes to your reproductive organs and to your hormone levels cancer and its
treatment can affect your sexuality and sexual function it can also affect your sexual partners and your relationships
cancer treatments can interfere with some part of the fertility process and affect your ability to have children
different types of treatments can have different effects men may have a decreased sperm count if you are
interested in having children in the future speak with your cancer care team about sperm banking a woman's age is the
most important factor that determines whether or not chemotherapy will cause treatment induced menopause it is more
often permanent in women who are within a few years of natural menopause it may
not be permanent in younger women other factors that influence whether or not chemotherapy can lead to treatment
induced menopause include the type of drug the dose of the drug and the length of the treatment the symptoms of
treatment induced menopause are the same as natural menopause a low sex drive can
be caused by cancer treatment from the cancer itself or from treatment side effects like fatigue nausea or painful
intercourse the cause of your low sex drive may be short-term or long-term
birth control is very important for both men and women and pregnancy must be avoided while on treatment talk to your
cancer care team or contact the supportive care program if you need guidance with concerns about intimacy
and your relationships the Canadian Cancer Society has a patient booklet called sexuality and cancer and Cancer
Care Ontario has one called intimacy and sex that are great resources
here are some tips to help you on your treatment days the length of treatments
vary your cancer care team will advise you around how long your treatment will be we're comfortable warm clothing with
sleeves that rule up so your nursing staff can access your veins and your PICC line do not wear fragrances or
perfume as many patients are sensitive to smells and the hospital is a scent free environment this also applies to
visitors you may eat before and after your treatment patients are permitted to
eat in the chemotherapy room however visitors are not you are welcome to bring your own food and drink with you
take your regular medications as you normally would on the day of your treatment unless you have been advised
otherwise bring all of your medications with you including the ones prescribed
by your oncologist 1 support person only per patient is permitted in the
treatment room and children under 12 are not permitted in the treatment room it is advised to arrange for a ride to and
from your chemotherapy appointment we will now discuss safety precautions
while you are on chemotherapy treatment these precautions are to be followed during and for 7 days after you have
received your treatment it is very important to keep all chemotherapy out of reach of children it can take up to
seven days to filter chemotherapy out of your body during that time your body
fluids such as urine feces or vomit carry small amounts of drug waste
exposure to this drug waste can irritate the skin and be harmful to others and
pets if chemotherapy or body wastes splashes on your skin wash your skin
with soap and water and rinse for 15 minutes wear disposable gloves to clean up body
fluids such as urine vomit or theses double-bag sanitary napkins incontinent
pads diapers colostomy bags in regular garbage bags and put in the regular
garbage for disposal at home linen and clothing contaminated with chemotherapy or body fluids should be washed
separately from other lebanon or clothing and washed twice in hot soapy
water flush the toilet twice with the lid down to prevent splashing use a
condom during sexual activity pregnancy and breastfeeding should be avoided
while on treatment some important points to remember are to bring your completed
record of chemotherapy side-effects and your appointment schedule with you to each chemotherapy visit to carry your
cancer treatment record with you at all times and to show it to medical personnel such as a dentist family
doctor at a walk-in clinic or hospital emergency room if you are a patient there complete your symptoms matter
report upon arrival for your chemotherapy appointment arrive at least
15 minutes before your appointment time as arriving late may affect other patients monitor your temperature daily
check with your pharmacy before your first chemotherapy treatment to see if any prescriptions may have been faxed
there by your cancer care team and wash your hands regularly your cancer care
team wants to know if you have certain symptoms so it is important to call them for the following if you have had a
fever and after you have been to the emergency room please notify your cancer care team
if you have mouth sores or mouth pain nausea or vomiting lasting longer than
24 hours diarrhea lasting longer than 24 hours constipation and you have been three
days without a bowel movement and for any abnormal bleeding or bruising phone
messages are taken by a telephone clerk at extension to nine zero zero a nurse
will call you back please be advised that calls are returned based on the urgency of the
symptoms the Northeast Cancer Center is open Monday to Friday from 8:30 to 4:30
p.m. it is not open on weekends or statutory holidays telephone calls are
answered by a telephone clerk from 8:30 to 4:00 p.m. if you have uncontrolled
symptoms and the Cancer Center will be closed for at least 24 hours please seek emergency room care the
phone number to the Cancer Center is one seven zero five five two two six two
three seven extension two nine zero zero the toll-free phone number to the Cancer
Center is one eight seven seven two two eight one eight two two extension two
nine zero zero the supportive care program offers counseling to patients
and families coping with a cancer diagnosis they can help with your emotional physical and practical needs
that might arise due to cancer individual appointments and classes are available and services are available in
English and French disciplines available include registered social workers
speech-language pathologists physiotherapists registered dietitians
and an aboriginal patient navigator health care workers in this program can
provide professional consultation for nutrition related questions physical difficulties or lymphedema counseling
for coping with stress related to having a cancer diagnosis or help with financial and insurance matters the
Northeast Cancer Center has an aboriginal patient navigator for patients who are First Nation matey or
mu it to assist with accessing care and resources when coping with the cancer
diagnosis the navigator can help with transportation accommodation medical
coverage and family support patients may self refer to the
supportive care program or ask their health care worker to make a referral on their behalf family members may self
refer for social work services for further information or to book an appointment please call 7:05 five two
two six two three seven extension two one seven five you can also visit the supportive care
program on the first floor of the Cancer Center their hours of operation are from
8:00 to 4:00 p.m. Monday to Friday we will now discuss the pharmacy services
available at the Cancer Center the Cancer Center Pharmacy has three main
roles to dispense oral anti-cancer drugs and supportive care drugs to prepare IV
cancer treatment and to dispense medication for clinical trials to speak
to a pharmacist at the northeast Cancer Center you may ring the bell at the pharmacy window or ask a nurse to
contact one your chemotherapy dose is made uniquely for you based on many
individual factors such as age sex height weight and blood work results it
is important to let your nurse know if you think that your weight has changed a lot since they last weighed you once all
the above information has been reviewed and the doctor has confirmed the dose the pharmacy is then able to prepare
your drugs so please be patient if it seems that it is taking a long time for your drugs to be ready chemotherapy is
given on a specific schedule called cycles oncologists give chemo in cycles
with each period of treatment followed by a rest period to give you time to recover from the effects of the drugs
cycles are most often two to four weeks long the schedule varies depending on
the drugs used for example with some drugs the chemo is given only on the
first day of the cycle with others it is given for a few days in a row or once a
week then at the end of the cycle the chemo has scheduled repeat to start the next cycle you will receive
written information sheets about your treatment from your primary nurse
besides the benefit that you can expect from your chemotherapy there can also be side-effects it is important to know
that side-effects can vary from drug to drug and from patient to patient we will not be reviewing every possible
side effect today you can refer to your information sheets to review the side-effects generally reported with
each drug however we will discuss nausea and vomiting you may receive a prescription
for one or more medications to take before your chemotherapy treatment to
help prevent nausea and vomiting pick up your prescription before your first chemotherapy treatment appointment you
can fill your prescriptions at the northeast Cancer Center outpatient pharmacy or at your local community
pharmacy if the label says to take one hour before treatment then bring these
to your chemotherapy appointment and your chemotherapy nurse will tell you when to take them there are some
exceptions where you will be instructed to start your medication 12 hours before chemo or even the day before chemo in
these cases you should not wait until you get into the chemo room these must
be started prior to chemo read the labels very carefully for these new
prescriptions before chemo and if you are not sure when to take your pills too
please contact your cancer care team for guidance you may also receive prescriptions for medication to take at
home after treatment or on an as-needed basis if you have nausea or vomiting
despite taking medication before your treatment bring your regular medications
for example your pain medication with you to your treatment appointment so you have access to them while you are at the
Cancer Center it is recommended that you carry an up-to-date list of all the medications that you are taking
including vitamins and over-the-counter products as well as your cancer treatment record
keep these on you at all times in your purse or in your wallet so that other
healthcare providers can better help you if needed such as at a walk-in clinic or at the dentist's office drug
interactions in oncology are of particular importance interactions with other medications can cause small
changes in the action of the drugs on the body that could significantly alter its ability to work as intended your
written drug information sheets will list some of the more common drug interactions that can happen with your
cancer medicines you can also talk with the pharmacist about prescription drugs over-the-counter products herbal
medicines vitamins minerals and supplements regarding drug interactions
food interactions disease interactions natural health products may affect the
way your body responds to chemotherapy drugs therefore it is important that you speak with your oncologist before taking
any herbal and natural products while receiving chemotherapy the pharmacist will check drug interactions for all
chemotherapy patients and if there are any concerns they will speak with you directly in the chemo therapy room order
discuss their concerns with your oncologists while on chemotherapy it is
recommended that patients do not take anything with a si in it also known as
aspirin until they have talked to their oncologist first low dose once a day a
SI for the heart is usually okay to take there are many over-the-counter products
that contain a si some of the most common are enter Finn Novus n' Anacin
coated aspirin alka-seltzer Bufferin midol ro boxes all and 220 tooth it is
important to check with the pharmacist at the drugstore when buying a product that does not need a prescription to see
if it contains a sa non-steroidal anti-inflammatory drugs such as Advil
ibuprofen Aleve or naproxen can affect your bleeding risk like aspirin
speak with your pharmacist if you need over-the-counter pain relief for general over-the-counter pain relief purposes it
is recommended that you take tylenol or acetaminophen however make sure to check
your temperature before taking these medications to verify that you do not have a fever the Northeast Cancer Center
has a research department that conducts clinical trials this may be a treatment option that your oncologist presents to
you or if you are interested in learning more you may speak with your oncologist about it by participating in a clinical
trial you have the opportunity to better your treatment options or outcome of
your treatment help others by improving cancer treatments in the future and continue to take an active role in your
treatment plan speak to your medical team about the possibility of participating in a clinical trial or
contact the research services office at seven zero five five two three seven
three zero zero or by email at Rs o at HSN RI CA one last piece of advice is
for patients to use the internet with caution there are a lot of websites that provide information that may not be
accurate the following websites are recommended to research your type of cancer and treatment Cancer Care Ontario
British Columbia Cancer Agency Canadian Cancer Society and the National Cancer
Institute thank you for your time and attention if you have any questions that
were not answered in this presentation please contact your cancer care team