Episode 23: Patient Fundamentals - Coping with chemotherapy with Rachel Bryce, chemotherapy nurse

Chemotherapy is scary and we want to make it less scary for patients. Simple.

We talk to senior chemotherapy nurse Rachel Bryce from University Hospital Plymouth - she is also Macmillan lead systemic anti-cancer therapy (SACT) lead and UKONS SACT representative -  about what patients can expect and what to look out for expect on chemotherapy.

We think this is great discussion that could be used for anyone new to or dealing with chemotherapy.

We hope you enjoy.
John & Mike 

Transcript

Hello, I'm John McGrane and I'm doctor Michael Rowe. And in this episode, we're delighted to welcome Rachel Bryce, who is an advanced clinical nurse practitioner at University Hospitals Plymouth. She is also the National clinical advisor for systemic anti-cancer therapy (SACT) with the big Macmillan charity and is due to start with the UK Oncology Nursing Society Board as advisor for systemic anti-cancer therapy. So Rachel.
 Welcome. Today, what we're focusing on in this episode is specifically chemotherapy and what we mean by chemotherapy, cytotoxic chemotherapy for patients with a diagnosis of cancer. So welcome, Rachel.

 Rachel Bryce   1:31
 Thank you very much and thank you for inviting me today.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   1:34
 Hi Rachel. This is a very broad question to start with. Chemotherapy is a very emotive statement. People have certain things but what is chemotherapy and how is it working against our cancer cells in simple terms for our patients and listeners.
Rachel Bryce   1:52
 And so essentially, chemotherapy is a cancer treatment which uses drugs to kill cancer cells and stop them growing. And I'd say what's probably different about chemotherapy than a lot of other cancer treatments, especially recently, is that it's not just targeted to cancer cells. So the reason we get quite a lot of our side effects and things which we'll talk about, I'm sure in a bit is that chemotherapy effects both cancer cells and our normal cells.
 And so that's probably one of the most differences and but essentially it's there to stop cancer cells growing and kill the cancer cells.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   2:27
 And we use chemotherapy in in lots of different parts of a patient's journey with cancer. Can you give us an overview of when patients might be being talked about for chemotherapy?
Rachel Bryce   2:40
 Yeah, yeah, absolutely. So chemotherapy can be used in a lot of different situations.
 We know that there's over 200 different cancers, there's over 100 different chemotherapy drugs, and so they can be used in a lot of different situations so they can be used in the curative setting where we're hoping that the cancer does not return and we're able to cure that cancer completely. We can use it in a setting which you might hear in the hospital, which is called neoadjuvant, but essentially that means pre surgery.
 So when people have neoadjuvant chemotherapy, it's to then try and reduce that cancer down before then they go for their operation. We can use it in what we call an adjuvant setting, which is then after surgery. And then that's very much about reducing the risk of that cancer returning in the future. And then for a lot of our patients, we use it in what we call the palliative setting. And that's for our patients who unfortunately we know cannot be cured from their cancer. However, we are using that chemotherapy.
 To stop that cancer, trying to grow, trying to reduce that cancer and absolutely try and stop some of the side effects from the cancer. And I would say in our palliative patients sometimes if they see palliative on their letters and certainly patients have talked to me about it, it can be quite upsetting for them. But I've certainly got patients who have been on palliative chemotherapy for over a year and our patients live very well on palliative treatments for quite a long time. There are obviously those patients, sadly that don't and our treatments don't work. But I think if people.
 I see that we're palliative and it causes them any stress or they don't understand it. Then absolute speech oncology team about it.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   4:17
 And I often use the phrase non curative life extending in that situation just to try and reduce that anxiety, because sometimes people can be on those therapies for years.
Rachel Bryce   4:27
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   4:30
 Now when we talk about chemotherapy, there's different ways that it's given, I think. Could you just talk us through when it's given in? So we talk about intravenously and of course there's also chemotherapies that come as tablets. But if you could just talk us through that kind of process when somebody comes in for intravenous chemotherapy.
Rachel Bryce   4:52
 Yep, so intravenous would certainly be the most common way we deliver chemotherapy and it's usually delivered within a specialised unit within a hospital. However, it can absolutely be maybe in a Community setting, it could even be in someone's home or somewhere place in the country and have community buses which they have specialised buses, that they go around so having intravenous chemotherapy can be in a variety of places. But I'd say predominately in a hospital unit.
 A patient would come into that unit and what would be common throughout all intravenous therapy is it would be then administered by a specialist.
 Oncology nurse who were trained in the delivery of chemotherapy. The patient would then have a needle placed into their usually into their arm, or if they have a central line already, it would be given centrally into their line.
 Yes, John.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   5:43
 And you mentioned Central line, I think this is a great opportunity to just touch on those. Not everybody will know what a central line means, but to me there's two main types. One's what's called a PICC line and one's a Porter Cath. Do you want to just quickly talk about those?
Rachel Bryce   5:48
 Yeah.
 Yep. So we have a PICC line which is a peripherally inserted central catheter and they would go into the vein in the middle of your arm, which would be inserted and they all sit up into the into one of the chambers of the heart and with a PICC line, you would see an external line that is left out hanging and the patient would have that in.
 The advantages of having a line is patients then don't have to have needles every time. They can have their blood tests from them, and so often for our treatments they are thought of as a is a good option.
 We then have what we call like it can be a portal Cath or we sometimes call them tivats, which are under the skin. And so actually there's nothing external when the patient would leave the unit and there was just kind of a lump underneath their skin and then we access them with needles when they come into the unit. And again for patients, if they wanted to shower with their lines, if they like to go swimming, if they have young children or dogs or, you know, things that might affect the line outside then.
 Tibet is a much better option for them, and it's about talking to the patients about what's the best option for them at that time.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   7:06
 That's really helpful. And so I think actually the majority of chemotherapy is probably delivered through little cannulas in the arms that we take out, but there will be a subset of people who have these longer dwelling lines for access as well.
Rachel Bryce   7:18
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   7:19
 And.
 So we interrupted you very briefly. Then we're talking about lines. So you're in the process of talking about what happens in a chemotherapy unit for delivering chemotherapy. So first getting access to someone's veins, then what's the next step?
Rachel Bryce   7:34
 Yeah. So I'll probably just say my prior to getting the access to the veins, it's very important that that nurse will do an assessment to make sure you're fit for treatment on that day. So often you'll be asked a lot of questions about any side effects or symptoms you've had in that proceeding few weeks and it is incredibly important that patients are really honest with our nurses at that time about how they're feeling. And prior to the nurse then putting in a chemotherapy through on that line, they would absolutely have checked your blood test results. So it's really important that.
 All our patients, it's essential that they have a blood test before their chemotherapy and our trained nurses would then check those blood tests and check that those.
 Blood levels with within acceptable levels for that particular treatment and depending on what treatment you're on depends on what levels that they might be available.
 And so.
 The chemotherapy would then be given intravenously and depending on how many drugs you're having, so some patients have one drug, some people have two, some people have three and more and more common. Now people have a mixture of chemotherapy and another type of drug, and so it depends on what treatment you're having. You will then have those specific treatments given to you at that time.
 With varying flushes in between, and again your time on the unit could be half an hour and it could be 8 hours. So again, it's very specific to you and your cancer and your treatment about how long you're on the unit and how many drugs you're receiving at that time.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   8:57
 And one of the things that when I'm first talking to patients in clinic about giving them chemotherapy, one of their main worries is how they're going to feel whilst they're having the treatment. Can you tell us a bit more about that?
Rachel Bryce   9:11
 So I always say to patients, while you're having your treatment, essentially you should feel nothing, and if you are feeling something, there's generally a problem and you need to let us know. So if you're feeling, if you have a cannula in and at any point that starts to burn, sting feels uncomfortable. You absolutely need to let your nurse know straight away and we would stop the treatment and then investigate what was happening. The other thing that can happen is some of our patients, unfortunately do have reactions. And so again, if suddenly you're having that treatment and you're feeling.
 Difficulty breathing, swollen, itchy back pain reactions can come in very many different forms, and so why also to patients? Patients. If you feel any different while having that treatment, you've got to let us know because essentially for it to be normal for patients while they're having their treatment, you should actually feel nothing at all.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   10:03
 And.
 Whatever, there's a whole team effort delivering chemotherapy, you know, because the nurses in the clinic delivering the chemo in the unit delivering the chemotherapy. But there's pharmacists, there's labs working behind.
 You know, we have patients coming up for reviews, blood tests, you know, could you just talk us through that kind of process where you know people are reviewed and people might think, oh, I'm getting asked the same questions over and over again. But safety is such an important part. Whenever you're dealing with a relatively toxic treatment like chemotherapy.
Rachel Bryce   10:40
 Yeah. So I would say for us to keep our patients safe, the number one thing is actually our patients need to be fully consented and aware of all the side effects and symptoms to start with. And I think we have an obligation as an oncology team at all those stages, making sure they fully understand and are fully consented for that treatment because then if the patient understands when there are issues and what to raise, then it makes our jobs a lot easier to be fair.
 And within that.
 Process like you said John, there's loads a lot of people involved, so at the very start, our patients would have met an oncologist and they would have talked through their treatments and they would have been consented and that would be a fully informed consent that they need to then sign.
 And then at that process, depending on what treatment they're having and what schedule they were on will depend on how often they have to see their oncologist or oncology team and clinic. So for some patients, they have to see them every cycle and that could be face to face, it could be video, it could be telephone, but they have those scheduled in and the patient be aware there might be some patients who actually are seen only every few cycles.
 And it might be that they're seen, you know, at the beginning and at the end. So again, at the start of a patient's treatment, they have that have that conversation.
 Oncology team, but how often those reviews will take place and then that is then subject to change. So if someone is particularly struggling with their chemotherapy, if they phoned the advice line quite a lot, then absolutely we will see those patients with within those cycles quicker.
 So once a patient has been seen in clinic and the chemotherapy has been ordered, they then will go, they'll have the appointment scheduled on the chemotherapy unit and involved in the background. So yes , sorry John.

ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   

So Rachel, you mentioned cycles, do you want to just elaborate on that is just for what some of our patients who might not be aware how chemotherapy is broken down into those sections?

 Rachel Bryce   32:04
 Yeah, absolutely. So when patients start and they're told about what treatment they're going to have, often there's an aimed how many cycles or what we call treatments that they will have. So you could have an appointment where the aim would be to have eight cycles or treatments and usually you would have, say, four of those. And then maybe a scan and then depending on that, you'd have the other four and each treatment when you go for your chemotherapy, that would be classes day one.
 And then depending on the regime you are, you could have those weekly two weekly, three weekly.
 Very different to your individual treatment, but day one is when you go in for your first treatment that you would have.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   32:43
 And then you're usually reviewed in clinic by one of the team. Have your bloods done? Make sure things are safe. Make sure you're well enough. Make any adjustments before you. Then start the next cycle.
Rachel Bryce   32:56
 Absolutely, yeah.

 ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   12:22
 And would they have some kind of first visit conversation or pre assessment conversation just to reiterate some of the safety messages?
Rachel Bryce   12:31
 Yeah, absolutely. So in most centres, they will then have an, not all. Unfortunately they will then have a conversation which we call a new patient talk and around the country now they had been done in very, very different ways. So you might still see someone face to face for a new patient talk, you might see someone as a group. So there's certain places around the country doing group sessions. You might have a telephone call or we have now the my Sunrise app where people are doing it via the app and through video conferencing as well.
 And watching the videos and then have an appointment. And so there's very, very many different ways around the country that people are doing that, but it's certainly is absolutely encouraged that patients have some sort of new patient talk before to again reiterate all the side effects symptoms and safety measures that need to be in place.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   13:20
 Thanks Rachel.
 The we talked briefly on the potential side effects and reactions that you might be getting. Whilst the chemotherapy is being delivered and we also touched on the fact that there are quite a few side effects that we need to think about with chemotherapy. Can you touch briefly on some of the, the common general side effects that we'll be talking to patients about with chemotherapy and then also then what, which ones we're most worried about?
Rachel Bryce   13:46
 So before I start to talk to any patient about side effects, I think the one thing I will say is you can have two patients with exactly the same cancer size exact the same treatment and you have completely different side effects and that's one of the things we don't know much about at the moment is why patient A would have these side effects and patient B would have those. And so that's why it's really important to tell our patients about all the side effects and then say it's likely you're going to get a few to varying degrees but unlikely to get them all.
 And the most common ones we probably talk about.
 Things like hair loss. So again, not in all our chemotherapies, but in in some of them, you absolutely lose your hair.
 Constipation and diarrhoea, and again, we know some of our treatments are more likely to cause diarrhoea, some more like the Constipation. But equally, people can get either nausea and vomiting is one that a lot of people know about. And I think for especially for our older patients, they heard horror stories back in the day where nausea and vomiting was a real problem with chemotherapy. However, I would really try to encourage people that are medications now.
 So much more advanced than they ever were, and we can really deal with noise environment very well and skin side effects and especially round mouth. So because chemotherapy is stopping those cancer cells and normal cells dividing and growing, they also affect ourselves at a rapidly dividing cause most problems. So in our mouth our cells are rapidly dividing all the time and that is why it's those, you know, mouth care. It's really important because people can get a lot of mouth ulcers blisters.
 And struggle with their gastrointestinal tract. So yes, ma'am.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   15:19
 And what would you and what tips would you give them for that?
Rachel Bryce   15:22
 So really good math care on like regular mouthwash, a soft toothbrush. And I would say my main tip to anyone is to contact your advice line earlier rather than later. So if you contact us when it's first beginning to get sore, you might have a few blisters we can give you advice. We can prescribe medication. We will check if you've got ask about thrush because thrush is really common in our patients and really try to stop it getting any worse. However, if our patients contact us 3-4 days later when they can't eat or drink.
 That essentially then is a hospital mission. And so I think that's what I really try to say to our patients throughout is please, please don't worry about picking up that phone because if we get it at the beginning, it's easy to sort and it's not so easy when it's a really awful situation.
 And then I think what's really important to talk about is it's not just about physical side effects. And I think as healthcare professionals, we talk about physical side effects a lot, but there's then financial, social, emotional relationship, side effects. And I think we have to be really clear with our patients and be really honest about them about talking to that too. So from a counselling diagnosis, we know financially patients are worse off because they've got appointments.
 Or they're unlikely. Some people absolutely can work, but a lot can't. And going into the winter, people at home malls, they're heating bills will be higher. And so there's financial side effects. There's emotional, psychological side effects. People have a cancer diagnosis, they're going through cancer treatment that people are very likely sometimes to have low mood or affect their mental health. And again, I think we have, you know, to address that with patients and be able to talk to them about it.
 The social side of things, you know, they can't go often as out as much. It affects their daily patterns, their normal living. And although I would always encourage people to live as normal life as possible.
 Often with treatments they can't do that, and I think we have to acknowledge that. And then with relationships we know one of the big side effects of chemotherapy can be fertility. And I think it can be sexual function and it's really important that we bring these up with patients and explain what is important and try to put them through their relationships also. So when it comes to side effects, I think yes, we talk about physical a lot, but it's important to talk about all those others as well.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   17:34
 Absolutely, Rachel. And you know, it's very easy because there's so many, so many things to talk about. It's trying to make sure that we're touching on all of these important aspects with every single one of our patients. So the, the, the, some of the side effects we talked about are really important. They're the ones that happen quite commonly and can impact on sort of the general ability to feel well whilst on chemotherapy. But there are some also.
 Potential dangerous side effects of chemotherapy.
 Can you tell us a bit more about those?
Rachel Bryce   18:07
 Obviously the most dangerous side effect is unfortunately death from chemotherapy and we have to be really honest about that. I think when we consent patients, we have to use the word death and we have to say that they're rare. There is a proportion of patients that die because of chemotherapy at that time and not their cancer at that particular time. And I've sadly certainly had patients in my years and colleges that that has happened to. And I think because of that, that's what we have to really then go back to reiterating the point that if patients are unwell, certainly if they have temperatures.
 If they're getting these side effects, they have to get in contact with us.
 And because mainly because of the fact that their white cell counts are affected from not everybody but some proportion of patients and we lower patients immune systems. So they have a much, much lower ability to fight infections and because of that if our patients get an infection, it can get very, very sick, very, very quick. And I think it's just trying to not to scare our patients, but just to say to our patients that's why we do.
 Really emphasise that point about using our advice lines and especially if you get temperatures, especially if you're, you know, even if you've got a cold temperature that could be equally as bad.
 And so yeah, just get never worry about getting in touch with us because that can be the most dangerous side effect.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   19:19
 And those advice lines, just to reiterate their 24 hour advice lines manned by senior nurses.
 And if patients are getting a fever or shiverish or rapidly unwell, and they've got a thermometer and they check their temperature and it's above the target temperature that they then contact in at that time, that's not something we as a team want to hear about from the GP on Monday morning, for instance.
Rachel Bryce   19:43
 Yeah, yeah, absolutely, John. It's about your temperature above their 7.5 or below 36 is really important because the low temperature can be equally as important and depending on where you are in the country depends on what those lines look like. So absolutely every cancer patient should have a 24 hour number that they can call in those situations.
 But it will not necessarily be a senior oncology nurse, unfortunately, but it could be a call centre. It could be a medic at the hospital, but what I would say, which is really important is everybody should have that number.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   20:20
 Brilliant. Now we've talked about all of these side effects and actually during the consenting process, you usually list all of these horrible things that could happen and it makes it look like a patient might be going through the worst time of their life and it's going to be incredibly difficult. But actually we've got really good ways of managing some of these side effects. Both we as a team, but also patients as well. Could you talk us through how?
 We can manage these side effects.
Rachel Bryce   20:48
 They first or not to sort of reiterate the point. We can only manage them if we know about them. So the first thing is our patients have to tell us about them and then we can help to manage them. And for the physical side effects, there's often medication we can use and we have a whole range of medication for different side effects that we can turn to. And again, we use the drugs, you know, the medication that is most common that we use for symptoms, for example, for nausea and vomiting. However, we also know there's a proportion of patients that that won't be suitable for.
 So again, if that doesn't work, it's to really give our patients confidence that we can try something else.
 So one of the things is definitely from a medication point of view that we can use for these side effects. The other side of things is it might be one of the most common, probably what I didn't mention for side effects is fatigue, which our patients talk to us about and that is just that overwhelming tiredness and unfortunately probably is the side effect that can get worse throughout your treatment. And so there isn't a magic pill for fatigue, so something like fatigue, we advise on like exercise, maybe fatigue diary, there's different.
 Digital acts you can use.
 And just planning your week. So again it might not be a medication, but it's just about different changes in lifestyle that we would advise. And then there are now absolutely your clinical nurse specialist team, your oncology team, there's local support groups, your local Cancer Support Centre, there's national charity lines, there's like the McMahon helpline that people can use. And so I think you know if we know about side effects, it might not be necessary something we can directly help with. But hopefully we can signpost people to be.
 Get the help that they need.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   22:23
 And when people are on chemotherapy, I often say to them that they'll feel great for a couple of days because they've had steroids around the time of their chemotherapy. And then about day three, they might have that four to seven day period of the tiredness of if there's going to be nausea or other side effects or funny taste in the mouth or mouth issues, that tends to be that period. And then as the chemo comes out their system, they feel increasingly back to normal.
 But during that period, where they don't feel like eating, one of the tips that we certainly give people is.
 Little and often.
 And permission, you lose 5 PS of fatigue. You kind of if you can schedule yourself out of having commitments during that period where you know you're going to be just a little bit under par and then hopefully planning nice things during the period where you feel back to normal. It's kind of knowing how to map out that three-week schedule that is most chemotherapy cycles, isn't that right?
Rachel Bryce   23:20
 Yeah, absolutely, John. And I think often what you'll find with chemotherapy when you talk to your patients is they know very quickly what their schedule is. So they say to me, well, I know days four to seven, I feel really rubbish and I'm not going to plan anything. But I know then days 14 to 20, I feel much better and I might plan you know, to do something with my friends and go away. And also equally the physical side of things they say I know days two to four is where I'm really, really constipated. So I'm going to start those laxatives.
 The day or two earlier, because I know now that's coming.
 So I think it's that absolutely that patient knowing their body and knowing how their symptoms might develop throughout that time and absolutely making the most of these days, they feel the best. And then those days they know they're not going to, they're not planning very much just planning some time at home and trying to manage them the best they can.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   24:09
 And from a from an oncology point of view, we'll also be looking at what doses the patients are receiving of the chemotherapy as well. And there are ways we can change those doses and adapt it to the person in front of you depending on what side effects they might have had. It was also depends on what we're trying to achieve with that chemotherapy as well.
Rachel Bryce   24:29
 Absolutely right. And I think that's what's important for people to understand as well that we can make quite small adjustments to their chemotherapy, which will make huge benefits to them going forward for their cycles. So you know chemotherapy, we know obviously it's gone through research. We have the doses that we recommend and we will prescribe to those. However, everybody's body is different and so we could give someone 100% dose, but we absolutely flatten their immune system.
 We absolutely make them feel absolutely dreadful.
 And actually, without adjusting that chemotherapy, they wouldn't be able to have any more. But by actually adjusting that dose, it means that they can carry on with their chemotherapy in the various cycles that we want them to have. And it will absolutely have the effect we wanted to is what we hope. But we're not giving them all the side effects that they come with.

Now, Rachel, we've talked a lot about the problems with chemotherapy and actually to our listeners, you might be thinking, gosh, this looks like the worst thing possible. Why am I being offered this?
 But the reality is that we get a lot of people through chemotherapy and actually chemotherapy is an incredibly valuable tool.
 In treating cancer, can you tell us a bit more about that?

 Rachel Bryce   35:47
 Yeah, absolutely. I'd say we get the majority of our patients through chemotherapy because otherwise we wouldn't use it as a treatment. And I certainly have a large majority of our patients who get through chemotherapy quite well. They might have mild side effects, but actually doesn't really affect them. And actually it makes their quality of life a lot better and actually makes their symptoms a lot better.
 I certainly have patients who continue to work full time and maybe part time and so absolutely even working is not an issue for some patients.
 And so I think that's a really important part to say that actually it is really well tolerated for a lot of patients. But for the ones that it isn't and then we're here to support them.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   36:27
 That most patients will know somebody on chemotherapy that they don't know is on chemotherapy because they're tolerating it reasonably well.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   25:16
 And that's trying to reassure patients that in chemotherapy is a bit of a broad brush in the way it works as you described earlier. But the way that we can make it a bit more bespoke or individualised is adjusting the doses. If people are getting side effects for me, classically that's blood counts, struggling or pins and needles in the hands and feet tend to be an issue with the chemotherapies I give. And if people are struggling with that, reducing the dose to try and protect the patient and give a dose that is right for them as an individual.
Rachel Bryce   25:47
 Absolutely, John. And my current job, I'm working with older adults in cancer. And so I've got patients. Well, I've got an 86 year old and I'm just taking on 89 year old who were given chemotherapy too. And we know that those patients, yes, they might come across as quite physically fit and active. However, they will have 86 year old kidneys, 86 year old bone marrows, 86 year old livers. And so actually we do don't adjust at the start for those patients because we know that their bodies are not going to work. How regardless of how fit they want to tell you.
 They are. Their bodies are not going to work as good as a 40 road and so it's about looking at that patient from the beginning and trying to make the best judgement for them of how to keep them safe, because that's ultimately what we want to do.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   26:30
 Signpost. Any listeners who are interested in that specific point you've just made Rachel about chemotherapy or treatment for cancer in the older adults to another one of our episodes with Doctor Nicola Batiste, where we look at that in more detail. Rachel, that was we've covered a huge amount in a really relatively short period of time. Chemotherapy is a massive topic, but hopefully this has given our listeners a flavour for what it is.
 How we give it what kind of pathway that means and what kind of side effects they might expect and how we can manage that?
 We're going to come to the end now. I want asking you to do is to give us 3 takeaway points from today.
Rachel Bryce   27:10
 The number one would be is if you have a temperature of 37.5 or above or 36 and below you must contact your oncology team for your number and I think that has to be #1 because we say that to our patients all the time. I think for patients to understand that it's their cancer and their chemotherapy treatment and it's very individualised to you. And I think often patients will talk about their treatments, which is great to talk about with other patients. But always remember that's your chemotherapy, your side effects and just because you haven't heard someone else have it.
 And it's likely that you may, so, you know, be honest about your side effects and let us know. And thirdly, probably we aren't just interested in your physical side effects that always feel you can talk to us about all the other side effects that you might be experiencing too.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   27:54
 Am I allowed to put a fourth in?
Rachel Bryce   27:57
 Would you like to?
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   27:57
 I think I think I will.
 The fact that you're mentioning we've got people in their 80s on treatment chemotherapy is hugely daunting and it's often easy for us who work in it and we do it all the time to forget that. But people get through it, we support, we have teams of people not saying it's always easy, but we get people through chemotherapy, we adjust doses, we give supportive treatments.
 We can treat people in their 70s in their 80s with chemotherapy and get them through it, and it's a teamwork and it requires the patient and us, but I don't want people to go away thinking that it's not an achievable thing. It is absolutely an achievable thing and that's why your team will have discussed it.
Rachel Bryce   28:44
 Yeah. No, I completely agree, John. And I think you know we wouldn't be doing our jobs now if all we did was see people who were made incredibly poorly and actually what we see is we get people like you said through their treatment and we see people through the other end where actually we've made them feel a lot better and their cancer is a lot better. So absolutely, yeah. If it's right for you, it's the right thing to discuss with your team. And as you said, John, most of the time I get people through it.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   29:10
 Thank you so much, Rachel for your time. Really appreciate it, Rachel. That was excellent. And I'm sure there'll be lots of patients listening to this who would be relieved. We'll have some guidance and will really benefit from that advice. So thank you so much.

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