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Treatment Name: C10403 Maintenance

C10403 Maintenance is a Chemotherapy Regimen for Acute Lymphoid Leukemia (ALL)

What is C10403?
C10403 is an aggressive and complex treatment regimen for adolescents and young adults (AYA) with ALL. The C10403 regimen is similar to treatment regimens given to pediatric patients (less than 18 y.o.) and are typically more aggressive than regimens given to adults (40 years or older).

The entire C10403 chemotherapy regimen consists of 5 different treatment courses: induction, consolidation, interim maintenance, delayed intensification, and maintenance (this page).

C10403 maintenance phase (Course V) typically begins shortly after completion of the delayed intensification phase, unless white blood cell count or platelets are too low.

The Maintenance Phase of C10403 (Course V) consists of the following four medications:

  • Vincristine (Oncovin®)
  • Dexamethasone (Decadron®)
  • Methotrexate
  • 6-Mercaptopurine (6-MP)

Alternative name: 10403, CALGB 10403 maintenance (Course V)

How does C10403 work?
Each of the medications in C10403 are designed to target and kill acute lymphoblastic leukemia cells in the blood, bone marrow, or wherever else they may be.

Goals of C10403 Maintenance therapy:
C10403 maintenance is given to eliminate any remaining leukemia cells and maintain remission from the leukemia. The C10403 protocol is commonly given with the goal of cure.

Schedule

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  • Vincristine intravenous (I.V.) push or I.V. infusion over 10 to 15 minutes once per month (Days 1, 29, and 57)
  • Methotrexate oral tablets by mouth once per week starting the second week of each cycle (Days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, and 78)
    • Do not take methotrexate on each Day 29 when I.T. methotrexate is given during the first four cycles of maintenance treatment
  • Dexamethasone oral tablets by mouth twice daily for five consecutive days every 4 weeks (Days 1, 2, 3, 4, 5, then Days 29, 30, 31, 32, and 33, then Days 57, 58, 59, 60, and 61)
  • 6-Mercaptopurine (6-MP) oral tablets by mouth once daily (at least one hour after evening meal) every day (Days 1 through 84 = 3 months).
    • Different amounts of tablets may need to be taken on certain days of the week. Double check the prescribed daily dose each day before taking mercaptopurine
  • Methotrexate intrathecal (I.T.) injection on Day 1 of every cycle of maintenance treatment and also on Day 29 of the first four cycles of maintenance treatment which is the first year of maintenance therapy

Estimated total infusion time for C10403 Maintenance (Course V) therapy:

  • Up to 1 hour for Days 1, 29, and 57 of each cycle
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

In C10403 maintenance therapy, vincristine is usually given in an outpatient infusion center, allowing the person to go home after each planned treatment. 6-Mercaptopurine, prednisone, and methotrexate are taken at home.

Each maintenance phase is repeated every 84 days (12 weeks). This is known as one Cycle. For women, each cycle is repeated to complete a total of 2 years of therapy from the start of interim maintenance therapy. For men, each cycle is repeated to complete a total of 3 years of therapy from the start of interim maintenance therapy.

NOTE: 6-Mercaptopurine (6-MP) must be filled at a retail pharmacy. Not all pharmacies carry this medicine so it is best to call ahead to ensure it is in stock before going there in person.

Click here for the common C10403 maintenance starting doses.

Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported serious (grade 3 or 4) side effects of C10403 maintenance are shown here:

  • Neutropenic fever (17%)
  • Infection (16%)
  • Increased blood sugar (12%)
  • Numbness or tingling in fingers or toes (9%)
  • Mouth sores (3%)
  • Fatigue (3%)
  • Increased blood triglycerides (2%)
  • Blood clot (1%)
  • Inflammation of the pancreas (1%)
  • Bleeding (1%)

On average, 1% of patients discontinue treatment due to unacceptable side effects.

Side effect videos Side Effect Videos
Neutropenic FeverNeutropenic FeverFatigue Fatigue Blood ClotsBlood ClotsBleedingBleedingNausea and VomitingNausea and VomitingDiarrheaDiarrheaAnemiaAnemia

Monitoring

How often is monitoring needed with C10403 Maintenance (Course V)?
Labs (blood tests) may be checked before treatment and periodically in-between treatments if needed. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), blood methotrexate levels, plus any others your doctor may order.

How often is imaging needed?
Imaging may be checked before treatment and during treatment if there is a concern for infection or medication side effect. Imaging may include: X-rays, magnetic resonance imaging (MRI), or computerized tomography (CT) scans.

How might blood test results/imaging affect treatment with C10403 Maintenance (Course V)?
Depending upon the results, your doctor may advise to continue C10403 as planned, or delay or switch therapy, or reduce the dose of specific medications due to side effects or low blood counts.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

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Questions to ask your DoctorNursePharmacist

What are the best ways to minimize costs of treatment? Cost
One way to minimize costs associated with cancer treatment is to ask your doctor what types of tests they are ordering. If they are expensive, ask if they are covered by insurance before getting the test. If you are concerned about costs, you can also ask your doctor to only order tests that are absolutely necessary and to minimize the ones that are unlikely to change the plan. Some anti-cancer and supportive care medications are now available as generic formulations and preferred by insurance companies. If these medications are still expensive, ask your doctor to work with your pharmacist to find cheaper alternatives. Some drugs have co-pay cards or patient assistance programs that can help reduce the cost.
​Will this treatment cause birth defects if I get pregnant while I am receiving treatment? Fertility
Many drugs used to treat cancer have not been tested in women who were pregnant. You and your doctor should discuss whether a baby might be at risk for birth defects if you get pregnant while receiving anti-cancer medications. Similarly, the risks to a baby fathered by men taking anti-cancer medications are largely unknown. If you are a man about to take take an anti-cancer medication, you should first discuss the potential risks with your doctor.
Will I need to change what I eat during cancer treatment? Healthy Diet
Ask your doctor if a dietician is available to speak with you. The dietician can thoroughly evaluate what you eat (your diet) and can work with your doctor to come up with specific recommendations based upon your diagnosis and treatment. In general, most experts recommend that you consume a diet that has enough protein to ensure you maintain your muscle mass. Some experts recommend plant-based protein whenever possible (Reference). A diet that contains whole grains, fiber, fruits, and vegetables is generally recommended, but some experts caution that uncooked fruits or vegetables during eaten during periods when your immune system is greatly suppressed could lead to infection. Because many treatments do not suppress your immune system, you may be able to continue your normal diet. Ask your doctor and dietician what is safe and good to eat and what is not. Visit Stanford Health Care's website on nutrition for recipes. Additional Reference found here.
Am I able to safely continue over-the-counter and herbal supplements while receiving this treatment? Home Medications
Some over-the-counter (or "O.T.C.") vitamins or medications and herbal supplements may increase the risk of side effects of therapy, or cause the treatment to not work as well. Be sure to tell your doctor and pharmacist everything that you are taking, including prescription and non-prescription medications, as well as any eye drops, inhalers, topical medications such as creams or patches, implants or injections, which are sometimes forgotten but are all medications too!
What if I'm worried that the treatment won't work? Mindset
Our mindsets describe for us what is right, what is possible, and what is natural. Changing our mindset often requires a combination of education and communication with others. In general, mindsets can be shaped by our education and experiences, people we trust, the media, social networks, culture, or religion. When it comes to treatment, it is okay to be uncertain. Your doctor wants to do what is right and will only offer treatment they think will help. Try to change your mindset by talking with your doctor. The belief that treatment will help you meet your goals is powerful and may actually lead to beneficial physiologic changes in your body.(Reference)
How might I maintain a better sense of control? Mindset
Your doctor may have advice specific to your situation, and may recommend that you see a social worker who can listen to you and recommend specific resources, often at little to no cost! In the meantime, consider visiting our emotional wellness page to learn about our "Life H.A.C.Ks"
What do I need to know regarding my blood tests, which are sometimes referred to as "labs"? Monitoring
Unless you have access to them via your electronic chart, we recommend that you always ask for a copy of your labs. There are hundreds, if not thousands, of different blood tests available for your doctor to order. Some are common and some are not. Have your team explain to you what blood tests they have ordered and what the results mean when you do not understand. This way you will have a better understanding if the treatment is working or not. Plus, doctors may prescribe medications when your lab work is abnormal. When your lab work returns to normal you may be able to stop taking these medications, or reduce the dose.
Is it helpful and safe to exercise before treatment? Physical Activity
Physical exercise before, during, and after treatment has been shown to decrease the number of side effects and increase survival for patients with certain cancer types. You may not feel like exercising before treatment, but once you start feeling better ask your doctor about recommendations on the best way to start moving your body again in a way that is safe and beneficial. Importantly, you may have certain physical limitations now that may prevent you from doing certain exercises that may get better with treatment and time.
How can I keep track of all of my doctor visits, lab appointments, scans, and medication refills? Schedule
Your doctor and nurse will give you a schedule of treatments, including dates and times. They may be subject to change based upon your condition, your schedule, and the clinic's availability. There are many ways to keep track of things, including writing them in a calendar, or using your smartphone. To get started, try using our ChemoExperts Treatment Tracker to input the date and time of your treatments and appointments into the calendar. Then using your smartphone, put in the code you have generated and sync all events to your smartphone's calendar so that you won't miss a single appointment!
What can I be doing to reduce the number of side effects I may get? Side Effects
If you have a good understanding of what side effects to expect you can begin to take measures to possibly prevent them. Watch our side effect videos to learn more. For side effects that we do not yet have videos for, ask your doctor for ideas on how best to prevent them or if they occur, manage them appropriately. Doing so may keep you out of the hospital or even save your life!
Are there any long-term side effects associated with this medication, and if so, is there anything I can do to prevent them? Side Effects
Long-term side effects of anti-cancer medications are specific to each medication. Not all anti-cancer or chemotherapy medications have long-term side effects, but several have been associated with memory difficulties (sometimes called "chemo brain"), heart problems, diabetes, numbness or tingling in hands and feet, fertility problems, or fatigue. Ask your doctor if the medications you are receiving may cause any of these (or others) and if there is anything you can do to reduce the risk or prevent them altogether.
Will this treatment cause fatigue and if so, what can I do about it? Supportive Care
According to one large study, fatigue is reported by roughly 6 out of 10 people receiving treatment for cancer (Ref: Roila F, et al. Support Care Cancer. 2019). It is commonly described as the hardest side effect to deal with when receiving cancer treatment. In about half of these people, fatigue lasted for more than 4 months. The investigators also found that the most important factors related to the development of fatigue were decreased physical activity, poor sleep quality, pain, anxiety, anemia, and depression (Ref: Roila F, et al. Support Care Cancer. 2019). Fatigue may impact your relationship with others, and ability to work or have fun. It is often under-treated and importantly, medications are not always needed to make it better. If fatigue is an expected side effect of your treatment, or you feel it already, work with your doctor now on ways to prevent fatigue or to decrease its impact on your lifestyle.
What is supportive care? Supportive Care
The term "supportive care" was developed to describe the management of side effects from cancer treatment, but has been expanded to include all symptom management for patients before, during, and after treatment. Supportive care requires good communication among patients and health care providers, as well as family and caregivers. In addition to improving your physical functioning, supportive care also considers social, spiritual, and psychological wellness when considering ways to improve your quality of life. In addition to your doctor, supportive care is best delivered through a multi-disciplinary team, which may include specialists from nursing, pharmacy, nutrition, pain management, social work, physical therapy, and others. Ask your doctor what you can do to ensure your needs are being met and that maintaining the highest quality of life possible remains a primary focus of care. (Olver I, et al. Support Care Cancer. 2020)
How do I keep good records of my treatment history and what documents should I ask for? Treatment
We think the best way to keep track of things is to come prepared for clinic visits with pre-prepared questions, like this one! Then take good notes throughout each and every visit. At the end of each visit, ask your doctor for copies of your labs, scan results, pathology reports, and any other test results they might have.
What if my job as a caregiver is getting harder? Caregivers
Caregivers can be partners, children, parents, siblings, friends, or colleagues. Importantly, the needs of the person receiving treatment may first grow and not decrease until that person feels better. As a result, the primary caregiver may take on more tasks, such as cooking, laundry, house cleaning, or child care. Although being a caregiver can be both rewarding through improved self-worth, and relationship enhancement, it can become overwhelming at times too (Reference). Tell your doctor what has become most difficult for you to manage. And remember, it's okay to ask other potential caregivers for help with tasks to make your job as a primary caregiver a little easier.
What should I do if I receive a bill for something that I thought would be covered by insurance? Cost
On occasion, items may be submitted and denied by insurance for a variety of reasons. Sometimes the medication or procedure is not covered, but sometimes claims are submitted with too little information to be approved by insurance or sometimes claims are submitted with the wrong information (example: miscoded). A denial letter from the insurance company, when issued, usually helps to explain the situation. If you receive an unexpected bill, ask your doctor if there is a financial counselor or someone you can speak with to help you.
What foods should I eat during treatment? Healthy Diet
Ask if a dietician is available to speak with you. In general, most experts recommend that you consume a diet that has enough protein to ensure you maintain your muscle mass. Some experts recommend plant-based protein whenever possible. If you have had antibiotics recently, dairy products may be more difficult to digest and cause abdominal pain. It may take time to re-populate the good bacteria in your gut once antibiotics are stopped. Some experts also do not recommend probiotics and would advise you talk with your doctor and pharmacist before taking a probiotic supplement while receiving cancer treatment. In general, it is best to avoid highly processed foods, and those that have a lot of sugar. Ask your doctor or clinical pharmacist if raw fruits and vegetables are safe to eat with your treatment as these are often the best source of necessary vitamins and nutrients your body needs to stay healthy.
What if I do not feel like eating during treatment or if foods taste different to me now due to treatment? Healthy Diet
Some treatments are well-known to change the way foods taste. Some experts recommend avoiding your favorite food if it tastes different during treatment so that when you are finished with treatment, you will still enjoy eating it. In addition, if food makes you nauseated, try to avoid foods that produce a lot of aroma, or leave them uncovered so that they do not produce overwhelming smells when you take the lid off. If you are unintentionally losing weight, ask your doctor if you can meet with a dietician who can recommend specific foods that will help prevent further weight loss.
​What foods should I avoid while receiving treatment? Healthy Diet
Be sure to check with your doctor and pharmacist about foods that may interact with your treatment because certain medications may be affected. For example, grapefruit and grapefruit juice commonly interacts with certain anti-cancer pills.
What if my other doctors prescribe medications while I am receiving treatment from you? Home Medications
Before you start taking medications, it is usually a good idea to tell your hematologist or oncologist about newly prescribed medications from other physicians, physician assistants, or nurse practitioners to avoid any dangerous drug-drug interactions. If they do not know the answer, they will refer you to a pharmacist.
Do you recommend I make any lifestyle changes now, or is it best to wait until after treatment? Mindset
Now might be the time to start thinking about lifestyle changes. Are you avoiding things that make you unhealthy and doing things that build you up? Treatment will likely work better if you are in better physical condition! If you are feeling fatigued from treatment, watch our video on fatigue for some ideas on regaining energy.
​What if I am concerned about my sexual health? Who can I talk to? Mindset
Intimacy is an important part of many people's lives. Cancer and its treatment (surgery or medications) may cause anxiety, fear, a depressed mood, nausea, or fatigue, all which can lead to decreased sexual desire, decreased function and lower level of intimacy. It is a common problem and is probably underreported. Although it may be a bit uncomfortable to talk about at first, your doctor will understand. Certain medications may help improve your sexual health. Additionally, ask your doctor about the availability of counselors or other specialists that can speak with you and your partner. These specialists may have you fill out a brief questionnaire that will help them help you! Reference
​If I am having a hard time coping with the diagnosis, treatment, and all of the disruptions they have caused in my life, are there support groups available? Mindset
Support groups available online or in-person and may be offered by your treatment center. Ask your doctor which ones they recommend.
If I need to reduce the dose(s) of my treatment, will it affect how well it works? Prognosis
Certain anti-cancer medications can be reduced without affecting the overall chances of getting rid of the cancer. Your doctor or clinical pharmacist may be able to answer this question for you based upon the specific cancer and treatment. Sometimes dose reductions are made due to side effects. Other times dose reductions are made due to kidney, or liver problems when these organs are involved in breaking down the medication. In these instances, it is expected that the anti-cancer medication will achieve the same level in the body as it would in someone with normal kidney or liver function. Likewise, without changing their effectiveness, anti-cancer medications may require a dose reduction if they interact with another medication you are taking to treat another illness.
Is there anything that can be done if I am overwhelmed by the number of appointments for doctor visits, scans, and blood tests? Schedule
Ask your doctor if certain labs can wait to be drawn at the same time as others, or drawn a little early to avoid unnecessary trips. Or, ask if there are alternative medications that you might be able to take that do not require as many visits required for monitoring. Importantly, some tests should not be delayed or drawn early because they may affect your doctor's ability to make a decision that is important to your overall health.
How do I know when to call about a side effect and when to try to manage it on my own? Side Effects
Ask your doctor and nurse which side effects from your specific treatment are most concerning and when to call the clinic, or an after-hours on-call doctor for help. That said, sometimes even seemingly simple problems such as mild constipation should prompt a phone call to your doctor in order to prevent a small problem from becoming a major one, such as a complete bowel obstruction. Most importantly, by calling your doctor when you are not feeling well, side effects will be appropriately managed and you will feel better faster.
What can I be doing to take care of myself while receiving treatment? Supportive Care
It is important for a patient to be able to activate and support self-management, as well as engage in an exercise program that is safe and tailored to their abilities. Self-management refers to tasks related to the management of the disease or treatment, working with new emotions, and the possibility of changing roles in relationships in order to continue to live well with the condition (Chan RJ et al. Support Care Cancer. 2020). The delivery of information, such as that which is found on ChemoExperts.com, can help patients gain the knowledge necessary to begin to self-manage side effects such as fatigue, pain, diarrhea, constipation, and more. Certain side effects require immediate attention by your health care provider and it is important that you know what these are and when to seek immediate medical attention. In order to effectively take care of yourself, set goals with your doctor and formulate actionable plans that enable you to work through problems when you can, but also seek help in a timely manner when you need it. Ask questions when you do not understrand something. As clinicians ourselves, we see too many patients remain silent during their clinic visits. Now is your time to speak up!
What can I be doing to increase the chances of this treatment working? Treatment
Your doctor may recommend dietary changes, increased physical activity, or simply staying on schedule with all prescribed treatments. Tell your doctor if you are missing doses of medications and the reasons why. They are here to help you, not judge you, and would rather know so that they can give you the ideas or resources you need to be successful.
Now that treatment is over, can I start trying to have a baby? Fertility
Ask your doctor when it is safe to start a family or adding to your current one. If you used fertility preservation methods prior to starting treatment, your doctor may refer you to a specialist in reproductive medicine to help with having a baby.
Could persistent fatigue after treatment be related to what I eat? Healthy Diet
It has been shown in a clinical study of cancer survivors that a diet high in vegetables (particularly green leafy vegetables), nuts and seeds, whole grains, and fish was associated with a lower chance of having fatigue as well as lessening the severity of fatigue. In addition, it may improve the quality of your sleep. Just like exercise, sticking to a diet takes a certain amount of discipline, but it is worth it! Know that it may take time to feel the full benefits of incorporating more of these foods into your diet. If your diet could use improvement and feeling better matters to you, then give it your best effort to make these changes. You may lose weight and over time be able to lower the dose of, or even stop medications for high blood pressure or cholesterol if you take these as well.
Are there diet changes that might help prevent developing cancers in the future? Healthy Diet
Foods with whole grains (examples: wheat, bran, oats), those containing dietary fiber, and non-starchy fruits and vegetables have the best evidence for decreasing the risk of cancer. Ask your doctor if you can meet with a dietician to get healthy eating recommendations as well as recipes you may like.
Am I able to enjoy an occasional glass of wine or beer now that treatment is over? Healthy Diet
Alcohol can harm your liver and interact with certain medications. Moreover, alcohol is a known risk factor for developing certain types of cancer, therefore it is very important you do not drink alcohol without being cleared to do so by your doctor first. Important Note: this question only applies to those who are of legal drinking age.
How long do I have to continue new medications started after diagnosis? Home Medications
If you receive a cancer treatment that is given for a pre-specified amount of time, then you may be able to discontinue some of the supportive care medications shortly after you are done with treatment, such as antacids, anti-nausea, anti-viral, antibiotic, and anti-fungal medications. If you were taking a pain medication to treat cancer-related pain, and the pain is now improved, now might be a good time to consider trying to decrease the dose. This can be done over time, with help from your doctor, until you are no longer needing to take it.
What if I'm still experiencing anxiety after treatment? Mindset
Anxiety after treatment is natural and may come and go. If it is physically affecting you or your ability to sleep or socialize with others, talk with your doctor about it, and consider speaking with someone such as a social worker. Talking with someone can be very therapeutic, and may be better than taking medications for anxiety that may have side effects, such as fatigue.
How often do I come to clinic after this treatment is over? Monitoring
If the cancer goes away and you are in remission, your doctor will recommend a specific monitoring program for you after treatment is complete. There are many different types of cancer and they do not always behave in the same way. It is important that you follow your specific monitoring program which is designed to detect cancer (if it returns) early with the goal of making it easier to treat. If you miss a follow-up appointment or lab check, be sure to get it rescheduled right away. If the cancer is not in remission after treatment, your doctor may offer an alternative treatment if one exists.
What can I do if I'm having a hard time exercising? Physical Activity
Your beliefs about what you can do and your expectations regarding how your body will benefit likely have a strong impact upon whether you start exercising, and whether you stick with it. Some experts find that the most successful people make physical activity a part of their routine, just like you do with brushing your teeth. Over time, you will find that daily physical activity will lead to many health benefits for both your body and your mind. To avoid hurting yourself, consider starting out slow. Every little bit counts, especially when it becomes a regular practice. Ask your doctor about the best way to begin a physical activity program and whether they think seeing a physical therapist would help as well. Physical therapists can teach you new exercises and ensure the ones you are doing now are safe and beneficial.
What does the term "relapse" mean and how might it affect me? Prognosis
A relapse refers to the cancer going away and coming back within a certain timeframe. Generally speaking, if it comes back within a year or two, your doctor will likely discuss a second line therapy that you have not received before. If it comes back many years after the first treatment, your doctor may discuss repeating the original treatment since it was effective the first time.
What can I do if my treatment is over and I am still having side effects? Side Effects
It is not always easy to predict if side effects from treatment will go away or when. When speaking with your doctor, try to describe what is troubling to you and how it limits the things you want to do. By setting goals, you can tell if the interventions you make to reduce the side effect are helping you get closer to goal. For example, chemo brain (cancer-related cognitive dysfunction), may limit your short-term memory. Your doctor may be able to recommend treatments, including those that do not have more medications. (Chung NC et al. Oncology. 2018)
What can I do to get back to feeling like myself? Supportive Care
Many people are motivated to seek the information and tools necessary to speed recovery and reduce the chance of the cancer coming back. For both those living with or without active cancer, a primary goal is to improve the quality of life. (Doyle C et al. CA Cancer J Clin. 2006). Getting back to feeling like yourself might seem difficult, especially if you do not know where to start. Some people buy supplements thinking that pills will help them feel better. Unfortunately, these often do not work. If you are not quite feeling like yourself emotionally, physically, or spiritually, try to define what it is you want to feel like first. Being goal oriented may help you determine what the path forward looks like and what you need to do to reach your goals. (RJ Chan et al. Support Care Cancer. 2020). It may require that you talk with your doctor, who can further refer you to others for help when needed. For most people, the road to recovery requires that you maintain a healthy weight, get into an exercise routine, and eat a healthy diet.  Life after recovery from treatment is not always easy, and living with cancer can be more difficult. Set goals with your healthcare team to help motivate you. Believe in yourself because you can do it!
What can I do to help prevent the cancer from returning? Survivorship
Cancer prevention is of the utmost importance, especially when you have a history of cancer. Although this is a difficult question to answer, your doctor may have specific recommendations for you. Closely follow your doctor's recommendations for monitoring and don't miss or cancel clinic visits. In general, the World Cancer Research Fund International and American Institute for Cancer Research recommend the following: 1) Be physically active each day 2) avoid eating processed foods and try to avoid adding sugar to your foods or drinks 3) Eat mostly plant-based foods and limit red meat and processed meat consumption 4) It is best to avoid alcohol altogether, but if you decide to drink, limit alcoholic drinks to 2 per day for men and 1 per day for women 5) Limit processed foods that are high in salt 6) Use the foods you eat (vegetables and fruit), not supplements (vitamin or herbal pills), to prevent cancer. It's not always what you are eating, it's what you're not eating that matters too.
If treatment required me to stop working, when will I be feeling well enough to return to work? Work
The answer to this question varies based upon the type of cancer and treatment received. One study showed that people continually feel better the farther out from treatment they get, with improvement still seen for some as late as 18 months after the last dose of therapy. People with blood cancers and those that require chemotherapy, as compared to targeted therapy or surgery, may take longer to fully recover.
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Questions to ask your NurseDoctorPharmacist

Are there any programs that I can use to help minimize the cost of my treatment? Cost
If your cancer treatment is going to be costly, there may be financial or patient assistance programs available to you to help lessen out-of-pocket costs. Ask your nurse if any of these are available and if someone such as a financial counselor can help you. You may qualify for financial or patient assistance programs, or supplemental insurance. If you do not know your pharmacist, your nurse may be able to connect you with one that may help reduce the cost of medications.
What kinds of foods should I eat to prepare for treatment? Healthy Diet
Before treatment, ask your nurse if the specific treatment you are receiving is likely to change the way food tastes or if you are likely to lose weight. Now might be a good time to reevaluate what you eat on a daily basis. If you eat a lot of sugary or fatty foods, it would be good to eat more wholesome foods such as vegetables and fruits. Remember, it is not always what you are eating, it is what you are NOT eating that matters as well. Fruits and vegetables may contain valuable cancer-fighting compounds that may help you heal faster. If your healthcare team advises that you avoid vegetables, ask them for the written information that supports this recommendation.
Is it important to keep good records of my laboratory results? Monitoring
It is always a good idea to keep good records during your treatment course. Your nurse can help you get the records that you need.
Do I have to come to the clinic for labs or can I get them done at a facility closer to home? Monitoring
Some labs may need to be done at the clinic since not all laboratories have the ability to do them, but some routine labs could be done at a laboratory closer to home to save you a trip to clinic if it is a long drive. If you are interested in getting labs done closer to home, ask your nurse if this would be possible.
Which lab values are most important for me to keep track of? Monitoring
This depends upon your specific treatment, but in general, you should understand the normal ranges for your white blood cells, hemoglobin, platelets, serum creatinine (kidney function), and liver function tests (bilirubin, AST, ALT, Alkaline phosphatase). Your nurse may be able to help you understand what happens if your lab results are not within the normal ranges for these specific tests.
What side effects might require a trip to the emergency department? Side Effects
Some side effects can be life-threatening and need to be treated right away! Ask your nurse what side effects can be life threatening and if they occur, need to be treated at the nearest or emergency department (ED) or the emergency room (ER) designated by your health care team.
What can I be doing to reduce the number of side effects I get from cancer treatment? Side Effects
If you have a good understanding of what side effects to expect, you can begin to take measures to prevent them. Watch our side effect videos to learn more. For side effects that we do not yet have videos for, ask your nurse for ideas on how best to prevent them or if they occur, manage them appropriately. Doing so may keep you out of the hospital or even save your life!
What is a stem cell transplant? Stem Cell Transplant
A stem cell transplant is the infusion of stem cells collected from yourself, a related donor, or an unrelated donor. These stem cells restore white blood cells, red blood cells, and platelets after your own stem cells have been destroyed by high doses of chemotherapy and/or radiation. Your nurse may be able to further explain the process if a stem cell transplant is needed.
If I have an issue after normal clinic hours, what phone number do I call? Supportive Care
Serious issues can arise anytime of the day or in the middle of the night. Ask your nurse what on-call phone number you need to speak to a doctor or other healthcare professional after hours.
What can I do to support my caregiver? Caregivers
Encourage your caregiver to schedule rest and relaxation, have other friends or family members take "shifts" being the caregiver, allow friends or loved ones to cook meals, or find local or online support groups when time permits. It is important your caregiver continue to engage in activities that bring them joy, even though they may feel guilty stepping away from their role. Remind them they can't take care of you unless they take care of themselves first! Your nurse may have more specific ideas for you as well.
What should I look for to know if my caregiver is experiencing caregiver fatigue? Caregivers
If your caregiver begins appearing irritable, withdrawn, depressed, stressed, etc. they may be experiencing burnout. Changes in their sleep pattern and/or eating habits may also be a sign. Your nurse may know of other signs to look out for as well.
What if my caregiver is not available? Caregivers
It is important to have a designated back-up during the times your primary caregiver is unavailable or to have a plan in place for the times that they are not around. If you know you will have difficulty making it to certain appointments, ask your nurse if they might be able to reschedule for a time or day that works for you. If you need transportation to a health-related appointment, your social worker may be able to assist, but will need plenty of time to make arrangements for you. In the case of an emergency, never hesitate to call 911.
What should I eat if I am experiencing diarrhea during cancer treatment? Healthy Diet
In some cases, diarrhea can be caused by an infection. Be sure to speak to your nurse and care team before attempting to manage diarrhea at home. You should then consider trying the B.R.A.T. diet (banana, rice, applesauce, toast, oatmeal, or crackers) or bland foods. If you like dairy products, know that they may cause cramping in some people during treatment. If your stomach is bothering you, and you are having diarrhea, eat dairy in small amounts until you know you can tolerate a full serving.
How can I ensure I am getting adequate nutrition when I have no appetite during cancer treatment? Healthy Diet
When food becomes unappealing, focus on protein shakes, smoothies, electrolyte replenishing drinks, and broth. Ask your nurse to connect you with a dietician to help you with making food choices that agree with you. When all else fails, eat what you can! Most experts agree that a small snack that sounds delicious and stays down is better than nothing at all.
If I am admitted to the hospital, do I need to bring my home medications with me? Home Medications
It is always helpful to bring your medications so that your healthcare team can see exactly what you are taking and determine if you need any refills before you go home. Importantly, most if not all, medications will be supplied by the hospital. However, some medications such as oral anti-cancer medication or chemotherapy pills may not be routinely stocked and may not be readily available to the hospital's pharmacy. If this is the case, and your doctor wants you to continue to take your oral anti-cancer medication, you may ask the hospital if their policy permits you to use your own medication so that you do not miss doses. If you do bring your medications, and they allow you to use your own supply, it is important to know that hospital staff often require that they oversee the administration of these medicines so that they know exactly what you are taking in order to keep you safe. If they do hold onto your medications, make sure you ask for your them back before you leave since it is common for people to forget. Your nurse may be able to help answer more specific questions about medications brought into the hospital.
What do I do if I want to take natural or dietary supplements with anti-cancer treatment? Home Medications
Natural or dietary supplements are often unregulated and unproven. They may reduce the effectiveness of certain types of anticancer therapies or chemotherapy, or add additional side effects that you may not be aware of. Because of these things, herbal and dietary supplements are often not advised to be taken during treatment. That said, some supplements may be beneficial and even recommended. Importantly, your medical team can give you specific instructions on what to do if you are interested in these types of therapies. Do not start these therapies without speaking to your medical team first. If you would like to learn more about certain dietary and herbal supplements so you can ask more detailed questions of your doctor, visit this website sponsored by Memorial Sloan Kettering Cancer Center and scroll to the bottom to type in the supplement you are interested in knowing more about.
Who do I contact if I need a refill on my medications? Home Medications
To make sure that you don't experience any delays in treatment, make sure you ask your nurse who you should contact and how you should contact them when you need medication refills. Also be sure that they have your preferred pharmacy on file so they can send your prescription to the correct pharmacy.
If I am having mental health issues during treatment, what resources are available? Mindset
There are many resources that can help people deal with their diagnosis and treatment. Know that you don't have to face mental health issues alone. Talk to your nurse about what services are available at your treatment center to help with anxiety or depression, and ask what other mental health services are available in your area.
Who can help me stay active when I am feeling weak? Physical Activity
In order to maintain activity in a safe manner, ask your nurse to put you in contact with a physical therapist. They can assess your strength level and give you individualized exercises to maintain and build muscle safely. An example is to get up every hour during the day for a short walk in the house to maintain endurance. It might not be easy, but try to stick with it because it may greatly benefit you in the long run.
How can I prevent nausea or make it go away if I get it? Side Effects
There are many anti-nausea medications available. Of the ones you have been given, ask your nurse or pharmacist for guidance which to take and when. If you are having difficulty eating, anti-nausea medications taken 30 to 60 minutes before a meal can sometimes help. Eating soda crackers every couple of hours may help to absorb some of the acid in your stomach. Your nurse may recommend ginger ale, ginger chews, peppermints, or bland foods when you are feeling nauseated. Ensure you are maintaining proper hydration since being dehydrated can make nausea worse. Lastly, remember anti-nausea medications may have side effects too! Ondansetron (Zofran), the most commonly taken anti-nausea medication causes constipation in many people and may require the addition of a stool softener or laxative.
What side effects should I contact the clinic about if they happen? Side Effects
Ask your nurse which side effects should prompt a phone call and which side effects can be managed on your own. While certain side effects can wait until normal clinic hours to be reported to the clinic staff, some should not wait and need to be reported right away as they may be very serious or life threatening. Ask your nurse what side effects should be reported right away and should not wait.
What if I have trouble swallowing oral medications? Treatment
If you are having trouble swallowing your pills, your nurse can help you decide if you can take any steps to help make swallowing easier. Some pills may not be crushed, opened, or chewed without affecting how they work so contact your nurse or pharmacist before making any changes to how you take your medications.
How can I thank my caregiver(s)? Caregivers
A heartfelt thank you note or a small gift can be thoughtful ways to show your appreciation for the help you received during treatment and recovery. Although not your primary caregiver, your nurse will have likely played an important role in your care. Nurses are wonderful people and often do not receive the appreciation or recognition they deserve. If your nurse was exceptional and made a difference in your life, consider rewarding your nurse with a small gift if you find it within your means to do so, or write a thank you letter and address it to the place where he or she works.
Can I resume a normal diet now that cancer treatment is complete? Healthy Diet
Some dietary changes that were made during treatment may no longer be needed, while some changes should be continued even after treatment is complete. Talk to your nurse or dietician about any changes to your diet that can or need to be made now that you are no longer on treatment. If you ate a lot of sugary substances before treatment, it is probably best to limit how much you eat and ensure your body is fueled with wholesome, nutritious substances that will keep you performing at your best.
How can I return to a more normal lifestyle after my treatment is complete and not worry too much about the cancer coming back? Mindset
The fear of the cancer returning is a very common and normal fear to have after treatment is complete; however, it should not prevent you from enjoying life. Talk to your nurse to see what tips they can give to help you return to a positive mindset, similar to the one you had before diagnosis. If desired, your nurse can also help set up an appointment with a social worker if you have not already spoken with one. social workers may help connect with resources you did not know were available, which may help you regain a sense of control.
How often will I have to get lab draws now that treatment is complete? Monitoring
Monitoring may be required for some cancer types even after treatment is complete. Your nurse can advise you on how often these need to be done and where they can be taken care of.
How long will it take for side effects from treatment to go away? Side Effects
Some side effects may start to resolve shortly after stopping treatment, some make take time to resolve, and some may actually be permanent. It's important that you have appropriate expectations regarding which side effects may resolve and which may not. If your treatment has finished, tell your nurse what side effects you are still experiencing and what you can do to make them go away faster or lessen their impact on your quality of life.
What can I do to prevent fatigue or lessen fatigue if I already have it? Side Effects
Regular physical activity and a healthy diet are some of the best things you can do to get your strength back and lessen fatigue. Ask your medical team for specific exercises to do at home. Starting out slow and making small improvements is sometimes the best way to not feel overwhelmed or get frustrated when getting in to an exercise routine. If you want additional help, ask your nurse to arrange for you to see a physical therapist (PT). Many physical therapists have doctorate degrees and are experts in customizing a program that will help you regain strength and mobility.
What survivorship networks and resources are available to me? Survivorship
Even when treatment is finished, survivors of cancer may still find survivorship resources very helpful and valuable as they navigate life after cancer and begin to resume the things in their life that have been interrupted by having a cancer diagnosis and receiving treatment. Your nurse may be able to recommend some of these resources to you. If you receive treatment from a university hospital or large healthcare system, there may be programs offered within these centers that are available to you.
How long will I need my central line and when will it be removed? Treatment
Depending upon the situation, a central line may be kept for several years after completing treatment or it may be removed shortly afterwards. Your doctor or nurse can give you a better idea of how long your central line will be needed.
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Questions to ask your PharmacistDoctorNurse

Should my pharmacist know my caregiver's contact information? Caregivers
Yes, if you establish with your pharmacy that your caregiver is an acceptable contact person they can keep that information on file and use it when they cannot reach you, such as when you have new medications to pick up, or if there is a problem filling your medication.
Is my caregiver allowed to pick up my prescriptions? Caregivers
In most cases, a caregiver should be allowed to pick up your prescriptions from the pharmacy for you. Sometimes, a driver's license, government-issued I.D., or other additional information may be needed before a caregiver can pick up certain medications. Ask your pharmacist if any steps need to be taken before your caregiver goes to the pharmacy.
Should my caregiver go with me to my doctors visits, infusion treatments, and pharmacy to pick up prescriptions? Caregivers
It is often helpful for someone to go with you to help remember important things related to your treatment.  Because it is difficult to remember everything that healthcare providers say, this helper could also take notes on important information that you can both refer to at a later time during treatment. Your caregiver may want to listen to counseling by the pharmacist and take notes while they are teaching you about your medications.
How do I deal with being overwhelmed after receiving so many prescription medications? Mindset
Try your best to learn how to pronounce each medication, know how they work to help you, and what dosage you are supposed to be taking. If you feel overwhelmed by this, you are not alone! Ask your pharmacist to help you with each of these. After telling them all of the medications you take, ask them to help you figure out the best time of day to take each one. If you do not already have them, buy two pillboxes to help you keep track of all of the medication you take on a weekly basis. By using two pillboxes you will know when you need to refill a medication well before you run out.
Will physical activity affect the prescription drugs I am taking? Physical Activity
Most people do not need to limit the amount or types of exercise they do based upon the medications they take. However, there are some types of medications that can impact physical activity. Because certain medications may increase your risk of falling during exercise (examples include certain blood pressure medications, or anxiety or pain medications), it is a good idea to double check with your doctor and pharmacist to learn if you are taking any of these types of medications. Additionally, certain conditions such as having low platelets, or taking blood thinners may increase the risk of bleeding during exercise if the exercise is not done properly. Low platelets can occur as a side effects from certain cancer treatments or from the cancer itself. Ask your pharmacist if there are any medications you are taking that might be unsafe with the exercises you are planning on doing.
Who will help me organize my cancer-related medications? Schedule
A pharmacist can help you organize your medications so that you know what to take and when. Most retail pharmacies sell plastic drug organizers (pillboxes) that help with this process. Be sure to ask the pharmacist or nurse before leaving the clinic if there are any new medications you are supposed to pick up at the pharmacy.
What can I be doing to reduce the number of side effects I get? Side Effects
If you have a good understanding of what side effects to expect, you can begin to take measures to prevent them. Watch our side effect videos to learn more. For side effects that we do not yet have videos for, ask your pharmacist for ideas on how best to prevent them or if they occur, manage them appropriately. Doing so may keep you out of the hospital or even save your life!
What are the most important side effects I may experience from this cancer treatment? Supportive Care
Ask your clinical pharmacist if they have personal experience with other patients who have received the same treatment. Knowing you personally, they may be able to help you understand which side effects might be more likely to occur compared to others. Go to our Side Effects section and ask them to explain to you what it might mean to have any of the side effects we have listed. If you are deciding between cancer treatments, you may also want to compare the side effects of multiple cancer treatments by printing the Side Effects section alone and setting each of them side by side. Just remember to go through each one carefully because a short list does not always mean it is an easier treatment!
What if the cancer treatment prescribed by my doctor is denied by my insurance company? Treatment
If your insurance denies your medication, or prior authorization, your doctor may write an appeal letter, sometimes referred to as a "Letter of Medical Necessity" on your behalf. This describes the importance of the medication they have prescribed and why other treatments are either less likely to work or more likely to cause significant side effects that you may not tolerate. If the letter does not work and the cancer treatment is still denied by insurance, some drug manufacturers are able to offer free medication to individuals who qualify for their free drug programs. You may access these programs by calling the manufacturer, going to their website, or asking your clinical oncology pharmacist for help with this process. Not all manufacturers have free drug programs, so ask your pharmacist if they can help you determine if one is available.
Is it important to keep good records of my treatment history? Treatment
Keeping track of your treatment history is important especially if you are seeing multiple doctors or use multiple pharmacies to fill your prescriptions. Accurate treatment records should include the names and dates each treatment was started and stopped, and drug doses (example: milligram strength) whenever possible. Ask your doctor or pharmacist if they can provide this information to you. Knowing your treatment history may also help you determine which treatments might be available as an option for you in the future. Knowing exactly what medications you have taken in the past and what you are taking now can also help your pharmacist figure out if certain medications are causing you specific side effects.
Will any of my cancer medications affect my work schedule? Work
In order to minimize interruptions to your work schedule, ask your pharmacist to help you understand how best to plan cancer treatments around work.
What if after the 1st of the year, or 1st of July my insurance plan resets and I cannot afford my out-of-pocket deductible? Cost
Ask to speak with a financial counselor, a pharmacist, or pharmacy technician that specializes in high-cost treatments. Most specialty pharmacies have these resources and should be able to help point you to potential resources, such as grant funding.
What if I become pregnant or if I father a child while receiving cancer treatment? Will my baby be affected? Fertility
The answer to this question may depend upon the type of treatment and the answer may also not be known. Ask your pharmacist to look for information (such as journal publications) about the outcomes of pregnancies when women became pregnant when receiving treatment themselves or when women became pregnant from a man who was receiving cancer treatment. Be sure to tell your doctor if you become pregnant during treatment since they may change how you are treated after having a discussion with you to learn what your goals are. Many times, but not always, cancer can continue to be treated throughout a pregnancy and a clinical pharmacist may be able to help.
What if my non-cancer doctors prescribe medications while I am receiving cancer treatment? Home Medications
Before you start taking new medications, it is usually a good idea to tell your hematologist or oncologist about newly prescribed medications from other physicians, physician assistants, or nurse practitioners to avoid any dangerous drug-drug interactions. Ask your pharmacist if they are able to screen newly prescribed medications for drug-drug interactions.
Are any medications I am taking preventing me from increasing my physical activity? Physical Activity
If you are taking many medications and you do not know a lot about them, it is possible that they may be causing side effects that are preventing you from doing the things you want to do. For example, people continue medications for constipation which may then cause diarrhea if they forget to stop taking them when the constipation resolves. Certain medications may contribute to profound fatigue that may be limiting the amount of activity you are able to do during the day. Some medications may be interfering with your sleep, such as prednisone or dexamethasone, if not taken early on in the daytime. If you would like to be doing more with your day, ask your pharmacist if you're taking medications that might be affecting your physical ability to exercise or mental ability to stay awake.
What can I do if I'm having trouble figuring out the best times to take my medications? Schedule
Talk to your pharmacist to try to minimize the number of times per day you need to take medication. Your pharmacist will make sure that the pills you take together at certain times of day are safe and will not interact with each other.
If I experience certain side effects during treatment, how long will it take for the side effect to go away? Side Effects
Depending on the specific side effect and how long the medication stays in the body, side effects may resolve quickly or take an extended amount of time to resolve. Your pharmacist can often give you a better idea of when to expect certain side effect to go away or decrease in severity.
If I am given multiple medications designed to take on an "as needed" basis for the same problem, how do I know which order to take each one? Side Effects
It is common for patients to receive multiple medications used to prevent or to treat symptoms such as nausea or vomiting, constipation, pain, or others. If you have received multiple new medications, it may be difficult to know which one to use and when. Based upon the medications you have available to you, ask your pharmacist to help you understand which medication is best to try first, how long to wait for it to work before trying something else, and when it may be best to call the doctor for help. It may take a little time and effort to learn about these medications, but it is well worth it. You may feel much better when you take them at times that they benefit you most and cause fewest side effects.
What can I do to take good care of myself and manage side effects during cancer treatment? Supportive Care
Start by watching all of our side effect videos. They are short and designed to give you background knowledge on the topic as well as ideas on how to prevent and treat each side effect. After watching our videos, ask your pharmacist about specific side effect management strategies for the other side effects listed.
If my prescription is expensive, am I able to ask for a smaller quantity of pills? Treatment
Both supportive care medications and anti-cancer pills can sometimes be very expensive, and either cost you or your insurance company a lot of money. Some medications are required to be dispensed by a pharmacist in their original container with the original seal on the bottle or blister pack (individually sealed medications supplied in a foil pack) and therefore the entire quantity shown on the bottle or blister pack must be dispensed. However, if the prescribed amount medication is more than one bottle or blister pack, you have the freedom to ask for less medication. Ask your pharmacist which medications can be supplied in smaller amounts if you are uncertain you will use the entire amount. Less waste may also be better for the environment.
I always seem to be running low on my medications. What can I do so that I do not have only one pill left at the time of the refill? Treatment
If you have prescription insurance, you are often permitted to refill your medication (if refills are allowed and prescribed) by the 80% rule. For example, if your prescription refill is for a 30-day supply, you may be able to refill it as early as Day 24. If you think you will be taking a certain medication for a long time, work with your pharmacist to determine the earliest date you can refill it to avoid running low on your supply. Additionally, if you plan to go on vacation, tell your pharmacist the exact dates (needed by insurance company) that you will be gone and ask them to get a "vacation override" allowing you to fill more than the typical "one month supply" of medicine so that you do not have to worry about trying to refill the medicine while you are away.
Should I get a pillbox to help me keep track of my medications? Treatment
A pillbox can help you keep track of your medications, even if you are only taking one medication daily. Because many of us lead busy lifestyles, it is easy to take a medication and then moments later think to yourself, "did I just take that?". Taking extra medication can be dangerous and leave you with not enough pills at the end of the month. We recommend buying two pillboxes that have at least two compartments for each day of the week. By placing your medications in a pillbox and filling two entire weeks. it will allow you to see if you have taken the medication on any given day when it is due, and when you are getting close to needing a refill. Check with your pharmacist first to see if each medication can go in your pillbox since some need to stay in the original container until right before you take it.
Will the side effects of the treatment affect my ability to work? Work
Tell your pharmacist what you do for work and they can help you understand which side effects might interfere with your ability to work. They may also be able to help you understand how certain side effects can be prevented, or which ones can be greatly reduced by taking the certain over-the-counter or prescription medications that might not affect how the cancer treatment works.
Who should I talk to (pharmacist, doctor, or nurse) about whether it is safe for me to work while taking or receiving cancer treatment? Work
You should first talk things over with your doctor.  If your doctor has specific concerns about the medications you are taking, he or she can talk to a clinical pharmacist for help. Your pharmacist may be able to help you appropriately time the medications you take so that any side effects experienced are less likely to interfere with your work and your life.
Who would I talk to about drug cost if I need other treatments? Cost
If you are now in remission, or between treatments, you may want to start with the person who helped you get approval for the first medication. Alternatively, if this was not a pharmacist, know that "clinical oncology pharmacists" are often excellent resources for help with co-pay assistance, grant assistance, or drug manufacturer assistance programs for cancer medications as well as most other medications as well.
How long after I stop taking treatment can I consider my fertility safe to move forward with having children? Fertility
Often times the answer to this question is specified in FDA-labeled package insert information. Ask your pharmacist to look this up and to update you and your doctor with the information they have found.
How will I know when I may resume normal activities after stopping treatment? Monitoring
Many drugs, especially oral medications, have guidelines in the manufacturer's package insert that help you know when it's okay to resume normal activities (diet, sexual activity, breast feeding, and others). Ask your pharmacist to look up the answers for you, or ask your nurse or doctor if you have more specific questions.
Are there any side effects that I might experience even after treatment is completed? Side Effects
Most side effects occur while you are actively receiving treatment, but in some cases certain side effects can occur months to years after treatment is complete. Based upon the treatment you received, ask your pharmacist if there are any side effects that you should watch out for in the future.
Are there any medication(s) that I can stop taking after therapy that will help reduce side effects and help me feel better? Supportive Care
Your doctor will ultimately decide which medications you can stop taking but you should also ask your clinical pharmacist to review all your medicines to see if there are any that are no longer needed.
Are there any medications or supplements I can take to keep the cancer from coming back? Survivorship
If you are interested in any medications or supplements to prevent the cancer from returning, talk to your pharmacist before starting any of these treatments. Your pharmacist can explain the potential benefits and risks of taking any of these medications and help you decide if any of them may be right for you. Be sure to ask before spending your money since supplements can be very expensive and may not be recommended by your pharmacist or doctor.
Where do I dispose of unused chemotherapy or other medications? Treatment
If medications are not expired, ask your pharmacist if there might be any chance of needing them again in the future before you throw them away. If not, they may know of programs that accept unused medications in their original container that are not expired. If there are no programs located nearby that can recycle your unused medications, call your local police or fire department to see if they accept and destroy medications. Alternatively, if you have unused medications and are concerned about someone else taking them, mix them with old coffee grounds or other food scraps before throwing them away. This may also be the most environmentally friendly way of disposing of them. Before flushing medication down the sink/toilet, first ask your pharmacist to advise you on the best way is to dispose of it. For more information, visit this FDA website on unused medication disposal.
How long after completion of treatment can I resume a full work schedule? Work
A pharmacist may be able to give you information about how long certain side effects are likely to last after the last dose is taken. Your doctor can assess your overall health status and provide advice regarding when they feel like you are ready to return to work based upon their assessment of your physical and mental health, as well as their experience with other patients who have taken the same treatment.

ChemoExperts Tips

  • Continuous exposure to 6-mercaptopurine (6-MP), rather than frequent stopping and restarting, has been shown to have better anti-leukemia effect. If 6-MP is causing side effects to the point where it is difficult to take, talk with your doctor to see if reducing the dose may be safe, yet still effective
  • It is usually recommend to swallow mercaptopurine tablets whole. On occasion, your doctor may have you split them in half. However, the dose of mercaptopurine per week can often be achieved by alternating the number of tablets you take each day. Your doctor or pharmacist should tell you the exact number of tablets to take on each day of the week.
  • Unless your doctor specifically tells you it is okay, you should NOT take allopurinol while taking 6-MP due to a drug interaction between these two medicines. If taken together, the allopurinol could lead to an unsafe build up of 6-MP in your body or cause the 6-MP to be less effective
  • An antiviral medication such as acyclovir or valacyclovir (Valtrex®) is usually prescribed to prevent viral infections and is taken throughout therapy, including the maintenance phase (Course V)
  • A medicine known as sulfamethoxazole/trimethoprim (more commonly called Bactrim®), is prescribed to prevent a specific type of pneumonia known as pneumocystis jiroveci pneumonia (PJP pneumonia). Because Bactrim can interact with certain medications such as methotrexate, even when methotrexate is given intrathecally, your doctor, nurse, or pharmacist will tell to hold certain doses to prevent potentially severe side effects from methotrexate
  • Omeprazole (Prilosec&®) or a similar medication may be given to prevent ulcers from dexamethasone, however it is best not to take omeprazole on the days that methotrexate is given as it could make the methotrexate more toxic
  • Patients may differ in the amount and activity of an enzyme they have that metabolizes 6-mercaptopurine, called TPMT. In some cases, genetic testing for TPMT may recommended before or during treatment with 6-mercaptopurine to test for low levels of this enzyme that could lead to increased side effects
  • Clinical outcomes may be improved by seeking treatment from a University Hospital or National Cancer Institute (NCI)-sponsored cancer center where there may be more experts with experience in treating patients with acute lymphoblastic leukemia
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for ALL. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for C10403 Maintenance, we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for C10403 Maintenance. Depending upon your income, they may be able to help cover the cost of:

  • Vincristine
  • 6-Mercapto­purine
  • Dexamethasone
  • Methotrexate Oral

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as C10403 Maintenance and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with C10403 Maintenance

Individual Drug Label Information

Vincristine (Oncovin®)

  • ​Vincristine MUST only be given by intravenous infusion. May NOT be administered any other way
  • Dosage may be reduced in patients with poor liver function
  • May interact with certain antifungal medications
  • Vincristine will cause death if administered into spinal fluid
General Vincristine (Oncovin) Side Effects
  • Nerve pain in hands or feet may increase after each dose. It is usually reversible if treatment is stopped or dose is adjusted
  • Hair loss is NOT common if vincristine is given by itself
  • May cause constipation; preventative medicines may help decrease or avoid constipation
  • Leakage into skin or surrounding muscle may cause severe irritation (extravasation)
  • Click on the vincristine (Oncovin) package insert below for reported side effects and potential drug interactions

Side Effect Videos
ConstipationConstipationPainPain

See DailyMed package insert.

6-Mercapto­purine (6-MP)

  • Is an oral tablet available in 50 mg
  • It is usually recommend to swallow mercaptopurine tablets whole. On occasion, your doctor may prescribe a half-tab to make a total daily dose. Ask a pharmacist before you split any tablets in half as this may not be necessary and could unnecessarily expose others to the medicine
  • Take without food, preferably at least 1 hour after evening meal. Food decreases absorption so it is best to take on an empty stomach to avoid possible decrease in effectiveness. DO NOT take with milk or citrus products
  • If you miss a dose, take the next dose as scheduled. DO NOT take two doses at once to make up for the missed dose
  • Store at room temperature and keep protected from light
  • Dosage adjustments may be required for decreased kidney or liver function
  • May interact with allopurinol. If allopurinol is used, the dose of mercaptopurine should be decreased and close monitoring should occur
  • May decrease the effects of warfarin. INR levels may need to be monitored more frequently and warfarin doses may need to be adjusted
  • May interact with olsalazine, mesalazine, or sulfasalazine causing an increased risk of side effects
  • Some patients may lack or have decreased activity in the enzyme that metabolizes mercaptopurine, known as TPMT. Genetic testing may be needed if unexpected severe side effects are experienced
  • Can cause fetal harm when given to pregnant women with the highest risk during the first trimester of pregnancy
General side effects from mercaptopurine (6-MP)
  • Commonly causes low white blood cells, red blood cells, and platelets
  • May cause liver toxicity which is often reversible when therapy with mercaptopurine is stopped
  • Can cause nausea, vomiting, and loss of appetite
  • May cause diarrhea
  • Skin rash or increased skin pigmentation can occur
  • Click on the mercaptopurine (6-MP) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue BleedingBleedingPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Dexamethasone (Decadron®)

  • Dexamethasone is supplied as an oral tablet or oral liquid
  • Dexamethasone may increase the risk of infection. Depending upon how much dexamethasone is taken, antibiotics may be prescribed to help prevent infection
  • Should be taken with food and with a large glass of water to avoid stomach irritation or ulcers
  • Should be taken before 6 p.m. when possible, to avoid trouble falling asleep
  • May decrease the response to vaccines; vaccines may need to be repeated at a later date to obtain maximal response
  • If taken daily for several days or weeks, the dose of dexamethasone may need to be gradually decreased (tapered) to avoid withdrawal symptoms
  • If you miss a dose, take the next dose as soon as possible
  • Should be stored at room temperature
General Dexamethasone (Decadron) Side Effects
  • May cause high blood sugar, weight gain, irritability, high blood pressure, difficulty sleeping, stomach ulcers, bone loss, muscle weakness
  • Click on the dexamethasone (Decadron) package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

Methotrexate Oral (Trexall®)

  • ​Is an oral tablet available in 2.5 mg
  • Methotrexate has the following FDA Black-Box Warnings. The risk of experiencing these side effects is much higher if methotrexate is not cleared from the body appropriately:
  1. Low red blood cells, white blood cells, and platelets
  2. Kidney injury
  3. Liver injury
  4. Severe diarrhea
  5. Mouth ulcers
  6. Stomach ulcers
  • Can be taken with or without food. Swallow tablets whole and do not chew or crush
  • If you miss a dose, call your doctor to see if you should make up the dose or not
  • Should be stored at 68° to 77° F
  • Dosage adjustments may be required for poor kidney function or poor liver function
  • May interact with non-steroidal inflammatory drugs (NSAIDs), aspirin, proton-pump inhibitors, phenytoin, and sulfa or penicillin antibiotics. These drugs should NOT be used the day before or the day of therapy with methotrexate. 
  • Ask your doctor or pharmacist to review your medications prior to receiving methotrexate 
  • Is harmful to the fetus during pregnancy. If you are of childbearing age, use multiple forms of birth control 
General side effects from methotrexate
  • Low red blood cells, white blood cells, and platelets
  • Liver injury
  • Kidney injury
  • Lung injury
  • Skin rash
  • Mouth sores
  • Nausea and vomiting
  • Diarrhea
  • Fatigue
  • Click on the methotrexate package insert below for reported side effects and possible drug interactions 

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue AnemiaAnemia

See DailyMed package insert.

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References

1) Curran E and Stock W. How I treat acute lymphoblastic leukemia in older adolescents and young adults. Blood 2015;125:3702-3710.

2) Stock W, Luger SM, Advani AS, et al. A pediatric regimen for older adolescents and young adults with acute lymphoblastic leukemia: results of CALGB 10403. Blood. 2019;133:1548-1559.

Created: December 6, 2019 Updated: January 25, 2021

What is Acute Lymphoid Leukemia (ALL)?

Acute Lymphoid Leukemia (ALL), also known as acute lymphoblastic leukemia, is a disease of the lymphoid cells found in the bone marrow. Lymphoid cells are responsible for developing into cells of the immune system called B-cells, T-cells, or Natural Killer cells. In ALL, immature lymphoid cells know as "blasts" replicate at a very fast rate. Sometimes blasts crowd out the normal cells in the bone marrow so that red blood cells or platelets are unable to develop.

Common symptoms of ALL include fatigue, infection, and bruising or bleeding. ALL is the most common cancer diagnosed in children, but is rare in adults. Most cases of ALL are considered "de novo" meaning that the cause is unknown; however, some cases can be linked to certain genetic syndromes. There is no staging system for ALL. Chromosomes are often analyzed to determine which mutations in the chromosomes exist. The effectiveness of the treatment may depend upon the specific chromosome mutations that are present.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose your therapy.

Common C10403 maintenance starting doses

  • Vincristine 1.5 mg/m2 (maximum 2 mg) intravenous (I.V.) push or I.V. infusion over 10 to 15 minutes on Days 1, 29, and 57
  • Oral Methotrexate 20 mg/m2 given as tablets by mouth once daily on Days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, and 78
    • Do not take methotrexate on Day 29 of the first four cycles of maintenance treatment
  • Intrathecal (IT) Methotrexate 15 mg injection on Day 1 of every cycle of maintenance treatment and also on Day 29 of the first four cycles of maintenance treatment
  • Dexamethasone 3 mg/m2 by mouth twice daily (total daily dose = 6 mg/m2) on Days 1, 2, 3, 4, and 5, then Days 29, 30, 31, 32, and 33, then Days 57, 58, 59, 60, and 61
  • 6-Mercaptopurine 75 mg/m2 oral tablets by mouth once daily (at least one hour after evening meal) on Days 1 through 84 (= 3 months)

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability.

What are adolescents and young adults (AYAs)?

The age range for this population is generally considered to be those between 18 - 39 years old, although this age range may vary slightly.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is Intrathecal (I.T.) therapy?

Intrathecal (I.T.) injection is a procedure where a needle is inserted into the spinal canal of the lower back to access the space that contains the cerebral spinal fluid (CSF). Typically, once the needle is inserted, a small amount of CSF is taken out and chemotherapy is then injected into the CSF. This is most often performed to treat cancer that is present in the CSF or to prevent cancer from invading the CSF. It is important that patients lie flat for 30 min - 1 hour after receiving an I.T. injection.

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium