What happens when you start chemotherapy?

Answer: Jeni Jones, Support Manager, Pancreatic Cancer UK

The first thing to remember before commencing chemotherapy treatment is that you need to sign a consent from, which is your agreement to undergo the treatment.  At this point, you can ask any unanswered questions and discuss any concerns with your oncology team.

If you have been offered chemotherapy for a diagnosis of pancreatic cancer, then it is likely that you will have been offered Gemcitabine. This is the most commonly used drug for pancreatic cancer in the UK. It can also be used to treat other cancer types ie: breast, bladder or lung cancers, but this is usually in combination with other drugs.

Chemotherapy is given in CYCLES. These cycles are at an equal interval apart, which allows for the specific action of the drug to take place. Most of the time, each cycle will only contain one dose of drug treatment. However, in the case of pancreatic cancer, each cycle contains 3 separate doses of the drug. The cycle is a 4 weekly regime - 3 weeks where you will have one dose of the drug per week, and 1 week which is your "week off".  This is known as 'Day 1, Day 8 and Day 15' and you will often hear the staff involved in your care talking about these specific days. Each chemotherapy prescription is prescribed and ordered on an individual basis. The dose is based on each patient's height, weight and body surface area.

The gemcitabine is given as an infusion, over 30 minutes. You will have a small plastic tube (cannula) inserted into one of your veins, and will be attached to a drip. The drip will more than likely be fed through a pump, which is programmed to deliver the chemotherapy at the correct time, and correct rate. After this is finished, the nurses will attach a small bag of fluid to "flush" through the line, thus making sure the entire drug has left the line, and making it safe to remove the cannula.

It is very important that if you feel any burning, pain or tingling at the vein site during the infusion, that you alert the nursing staff immediately. Very occasionally, gemcitabine can cause pain along the vein as it is being infused. Although this is uncommon, it is something which should be attended to straight away. It may be that the cannula has become dislodged, and the drug is infusing into the tissue, and not into the vein. The staff will stop the infusion while they check the vein site and make sure it is still in the correct place and working properly.  If there is a problem with pain during the infusion, then it may be that the infusion time has to be extended in order to complete it successfully. If this happens, then usually all subsequent infusions will be given over a longer time.

Generally speaking, you will need to be seen by the oncologist at the start of each cycle. During this appointment, you will have blood tests taken to ensure that it is safe to continue on with the next cycle. These will include a full blood count (FBC for short), kidney function tests, liver function tests and usually, tumour markers. The tumour marker used for pancreatic cancer is called CA 19.9. You may hear this being spoken about. On its own, this is not an indicator for what is happening with the cancer, but helps build a picture alongside other tests such as CT scans. The doctor will also take into account the clinical picture of the patient in front of them, for example, the person may be feeling a lot better having had chemotherapy, even though sometimes the scans do not show a change in the tumour. You will also be weighed, and your weight will be monitored throughout your treatment.

During this appointment, the doctor will ask you about any side-effects you experienced from the previous cycle of chemotherapy. It is a good idea, if you are able, to keep a brief diary of what these are. The specific questions the team might ask are the lengths of time which the side effects lasted for e.g. if you had had diarrhoea, when did it start and how long did it last. This may be important for influencing a decision on whether to reduce the dose of the drugs or not. Most side effects are graded from 0-4; 0 being no side effect and 4 being severe side effects. The oncologist will go through a specific list and ask you how you tolerated the chemotherapy. At this stage, if necessary, any medication changes or dose alterations can be done e.g. changing an anti-sickness drug to a stronger type, or reducing the dose of the chemotherapy. You may also have a physical examination of your heart and lungs, especially if you are on a clinical trial. If you have nothing to report, this may be omitted.

Once your blood results are back, the doctor or nurse will be able to tell you if you blood count levels are adequate for you to go ahead with the next cycle of chemotherapy. Some hospitals do not have the facility for all the blood results to be done quickly, so you may have to wait a day or two before having your treatment. You will be given an appointment to see the doctor again prior to your next cycle. If you do not have this before you leave the hospital, you should ask at the appointment desk.