It is clear the two authors know what they are talking about, both are seasoned veterans dealing with patients who are undergoing the daily rigors of treatment. Oncology nursing is a special calling and burnout is common. But there are also uncommon rewards as one nurse revealed, "I know I touched the lives of people as few others ever will, during the most extraordinarily time of their lives".

As authors of what could arguably be the definitive guide for cancer patients facing the challenges that lie ahead, McKay and Hirano remain a reservoir of strength and calm from which to draw. Experience has taught them when, how, and why the questions come. And come they do. For those of us who have never known the complexities of an IV, the simple line drawings of a catheter may be a little frighting, but for those who live with one for many months they are normalizing and reassuring. And yes it is true, your hair will grow back! Unless, of course, you were bald to begin with.

Staff writer, Heather Pitre, interviewed the two authors this month for some exclusive insight into the making of "The Chemotherapy and Radiation Therapy Survival Guide."

-Valen Watson, Editor, PRC Website

What was your inspiration for writing this book? Can you tell me about the history of this resource?

Every nurse is a patient educator. We teach people about their medications, coping with problems etc. Over the years we found that we were saying many of the same things again and again. We wanted information to be available to people whether or not we were speaking directly to them. We also wanted them to have access to that information again if they forgot what was said. We try to communicate not only information, but also the attitude that they can get through this time, they are not alone, and help is available.

There are things people can do to help themselves during the time they are getting therapy - to feel more powerful, to feel better able to cope, and to manage symptoms. We know when people are first diagnosed, they are so overwhelmed with information about their disease, treatment options, test results, biopsies and pathology. This is a whole new universe they have to learn about and adjust to. We wanted to provide information, from one source, where people can turn to get the support they need during this time.

How has the book expanded on the 1993 edition? What has changed since then?

We had a lot of patient feedback after the first edition which influenced us to expand the scope of the book to include radiation therapy. The book now includes a general explanation about how radiation therapy works written by Dr. Myles Lampenfeld, the director of our Radiation Therapy Department. And every chapter in the book now includes symptom management for both chemotherapy and radiation therapy. They work differently. Radiation affects the part of your body exposed to the radiation. Chemotherapy travels through the blood stream and affects cells throughout your whole body. You won't lose your hair on the top of your head, for example, if you get radiation therapy to your hip.

In your work with patients, what kinds of specific experiences led you to create this in-depth resource?

When we talk with a patient for the first time, we learn a lot about their concerns. When the physician discusses their treatment plan, often you can see that their anxiety level is such that they may not remember everything. It's only natural to fixate on the things that worry you the most. For instance, someone may be worried about nausea, or hair loss, or finances. We expect people to need information repeated again and again over time.

That is why we wrote the book. This book was not designed to replace contact with the doctor or nurse - but to supplement it and to be a source of basic information. Rather than sorting through a series of handouts, patients can turn to a chapter in the book and find some answers to a specific problem or concern. We think it makes people feel more empowered, which, in turn, helps.

As you mentioned in the book, it's a commonly held belief that chemotherapy automatically equals constant feelings of nausea. I'd like to focus specifically on coping with nausea. What treatments cause this reaction? What is the physiological response as a result of taking the chemo medications?

When you say "chemotherapy" to people, the two things they associate with it first are hair loss and nausea. These days, with the medications available and the interventions we have, many people do not have nausea and vomiting at all. In terms of the physiological response, there are a number of different reasons why chemotherapy causes nausea and vomiting. The chemoreceptor trigger zone (CTZ) and the vomiting center in the brain are affected many different ways by different medications. The way the body protects itself is to rid itself of things that it registers as "unhealthy". It's almost like a defense mechanism. If you ate bad food, what would you do? You would probably vomit. Or, if it got past your stomach, you might have diarrhea.

Your cerebral cortex ( the thinking part of your brain) can cause nausea even without chemotherapy. When you have a bad experience of vomiting or feeling nauseated, your brain remembers it and makes an association with whatever caused that experience. The next time you see or smell or taste that same thing, you will become nauseated. This is called "anticipatory nausea and vomiting". If someone experiences severe nausea associated with treatments he might feel nauseated when he sees anything associated with that event - he may feel nauseated when just walking into the center even before his treatment. He may feel nauseated if he sees his doctor or nurse in the grocery store! We work very hard to prevent patients from experiencing nausea in the first place so this won't happen.

There are other reasons for someone to experience nausea during this time that do not even have anything to do with the chemotherapy. Your stomach may slow down, and if you feel very full and that can make you feel nauseated. There are medications that can help relieve that symptom. People can also feel "motion sickness" where they feel O.K. unless they move. There are a number of medications that deal with nausea and it really depends on how each patient is describing what he/she is feeling.

People who are just starting treatment and have a lot of anxiety about nausea are tremendously relieved when we talk about prevention. Although we can't prevent nausea every time for every patient, that is our goal. We tell people that if their chemotherapy is likely to cause nausea, they will be given medication to prevent it from happening - even before they get the chemotherapy. (We use the word "prevent" frequently, and on purpose. We tell them some anti-nausea medicines last for 24 hours and that they'll go home with more medication to take at home, and instruction on how and when to take it. We want to prevent nausea and vomiting for the first 24-48 hours when the problem is likely to occur, and they have the means to do that. If one medication is not working, there are others we can try. People appreciate that nausea isn't something they have to endure, but it's a reason to call us, and discuss different options. We can give them reassurance, when first teaching them about their treatments, that they are not alone, and that we'll try to prevent nausea from happening.

It's also important to remember that not all nausea is caused by chemotherapy. They may be taking other kinds of medicines that can cause the problem. Pain medication, antibiotics, dehydration, or constipation may also cause nausea. We never want to hear that a person was nauseated but that they "got through it". We want them to call us so we can discuss it. We want people to work with us as a team - that's the message. would you do?

Is dehydration the main danger if someone is vomiting?

Dehydration and electrolyte imbalances are both a problem. Also, if people are feeling very sick, they won't want to continue their treatments. If we can get someone through the chemotherapy, their chances of survival are better. We have a patient now who is questioning whether she wants to continue chemotherapy because she had nausea and vomiting with her first treatment. Now that we know what she experienced, we can change the anti-nausea medication to something that may work more effectively, and help her prevent nausea next time. If she feels better after the second treatment, she's more likely to keep going and complete her treatment. That's what we want - to prevent the problem. If you get dehydrated, you can then become nauseated. That can then cause you to not drink leading to dehydration which intensifies the nausea. It becomes a vicious cycle. Also, dehydration can lead to kidney problems.

What new developments are you seeing in treatment? Are there new drugs that have promising results?

When we talk to patients who had chemotherapy years ago, and are now getting it again, they say the experience is very different because of the new anti-nausea medications. We now have seratonin antagonists that have revolutionized chemotherapy in terms of preventing the problem of nausea and vomiting. We also may use more than one drug to prevent the problem. Patients may get, for example, a seratonin antagonist to block serotonin receptors in the brain. They might also get medication to help them relax or lower anxiety. Or, they might get a medication to speed up the GI system so the food doesn't cause an uncomfortable "full" or queasy feeling. Other drugs work at the dopamine receptors, or to prevent feelings of motion sickness.

We want patients to feel comfortable and be able to eat and drink If they can stay well hydrated and eat enough, they can recover more quickly and process the chemotherapy as well as excrete the by-products more effectively.

In your work at Alta Bates how has your book been used by patients and physicians so far?

Here at Alta Bates, it's given to all our new chemotherapy and radiation therapy patients, and we have received funding from a number of drug companies who have also supported it. The publishing company has made it available to us at a discount so that we can buy hundreds of books at a time. It's used as a supplement to the one-on-one patient education that the nurses here do. We can refer a patient to a specific chapter as needed. When people come back again, they'll understand more about symptoms, side effects, blood tests, etc., and how they can help themselves feel better.

I can see how that would help patients educate themselves, and become prepared for treatment. In terms of coping skills, I was intrigued by the visualization and relaxation exercises you mention. How can these skills play a part in treatment?

We think it's important to ask each patient how he/she copes with stress. There are no basic rules. You can't say if you visualize, or meditate, or talk to a friend, everything will be fine. We tell patients to go home and think about what makes them feel supported, relaxed and comfortable. Some people need a lot of information. They want to know everything, and they do research on the Internet and bring articles to their appointments. Other people don't want to know too much. They cope better by thinking about something else, or reading a book. We want to support individual coping styles.

One of our social workers here, Harriett Sanders Karis, runs support groups and visualization groups. She has also written visualization and relaxation scripts for our book that people can use to create their own relaxation tapes. These techniques work for people who are dealing with a stressful situation whether or not they have cancer. They can create a wonderful healing experience.

Can you give some ideas of other resources that would be useful, both for coping with nausea and for coping with cancer in general?

We often recommend the National Cancer Institute materials. They offer a booklet called Chemotherapy and You. The Wellness Community and the American Cancer Society also offer good resources. We also recommend support groups for patients who are interested. It is valuable to be with people who have gone through the same kinds of experiences. Support groups can be a place where people can share if they want to and know that everyone in the room knows exactly what they're feeling. By Heather Pitre