Our mission is to provide state of the art medical care with personalized service. We strive to understand the special concerns and needs of our patients. We make every effort to provide a warm and comfortable environment. We honor the doctor-patient relationship as an important element in the healing process.

Our areas of expertise:

Medial Oncology: Cancer

Hematology: Blood disorders

Appointments
Our office is open for scheduling appointments between 9 a.m. – 4:30 p.m. , Monday through Friday. We are closed for most major holidays. Please notify us within 24 hours of your scheduled appointment if you need to cancel your appointment. This will allow us to reschedule your appointment and accommodate other patients.

Please bring a current list of your medications, including dosage and directions, to each appointment. This list should include prescriptions, over-the-counter medications and supplements.

Our staff schedules your follow-up visits, treatment visits etc. Always be sure to see the receptionist before leaving.

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Telephone Calls
Non-emergency calls, such as appointment changes, prescription refills and insurance problems should be made between 9 a.m. and 4:30 p.m. Our telephone is answered 24 hours a day. On call physician is available for emergent medical issues during the after hours. In case of emergency please call 911.

Test and Test Results
When having radiology test, scans, biopsies or any other procedure done outside our office please know that we will make every effort to obtain the results as soon as possible. However, it could take 3 to 7 business days for those results to reach us. You may help expedite the process by reminding the person doing the test that you need results sent to your doctor here as soon as possible. 

Requests for Refills
Refills for medication, including those medications that have no remaining refills, should be called directly to your pharmacy. Your pharmacy will call us for refill authorization, if necessary. Please ask for refills atleast 3 business days prior to when your prescription is going to run out.

For controlled substances (eg narcotics), you must call our office during office hours, not the pharmacy. These prescriptions need to be obtained from our office and hand-carried to the pharmacy by you or an authorized patient representative/family member.

Requests for Medical Records 
If you are in need of a copy of your medical records, please call the office atleast 4 working days in advance and we will be happy to prepare them. 

Emergencies
If you have a true medical emergency, call 911 or go to the Emergency of the nearest hospital.

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Payment for Services
We recognize the need for a clear understanding between you and our office regarding payment for services. Charges for professional services and treatment depend upon your diagnosis and the terms of your managed care contract. Co-payment and unmet annual deductibles are payable at the time of your visit. We accept cash, check and major credit cards (Mastercard and Visa)

Insurance
Based on the number and different types of insurance coverage, it is best to contact our office if you have any questions concerning the types of insurance plans accepted by us. It is also difficult to list individual coverage options and/or benefits. 

Please notify us immediately if there are any changes in your coverage, employer or Primary Care Provider. When a change occurs, we will verify the new coverage and inform you of any changes in your benefits in order to ensure a smooth transition. 

Referrals and Pre-Certifications
Your insurance may require a referral from a primary care physician (PCP) in order for you to see a specialist. Your insurance may also require pre-certification of office or outpatient services. As a courtesy, our office will make every reasonable effort to obtain these referrals and pre-certifications for you. If a referral or pre-certification cannot be obtained prior to the date of your visit, your appointment may have to be rescheduled. 

Referrals and/or pre-certifications are sometimes required for CT scans, x-rays and other diagnostic tests. Some managed care contracts specify the location for these services. Our staff is trained to help our patients through this process and will answer any questions you may have.

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COMMUNICATING

Talking to Your Doctor and Health Care Providers
Your doctor and our staff are specialists in cancer, the fight against it, and all the emotions that come with it. We strongly encourage our patients to ask questions and to take an active role in their treatment process.

Tips for talking to Your Doctor
You may find it helpful to write down questions prior to your appointment. You may not remember everything you want to ask your doctor. When you do get answers to your questions, write them down, too. That way, when you go home, you won’t forget and you will be better equipped to answer questions that your family may have. If possible, bring a friend or family member to sit with you while you talk with your doctor. This person can help you understand what your doctor says during your visit and help refresh your memory afterward. Remember that your family and friends are there for you and want to help you.

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Surgery
An operation is done to remove the tumour. Surgery is often used if the cancer is only in one area of the body and has not spread.

Radiotherapy
This is the use of high energy x-rays to destroy cancer cells. The radiotherapy is aimed at the affected area of the body and is very carefully planned. It can cause side effects and the most common is tiredness. The side effects will depend on the part of the body that is being treated.

Chemotherapy
Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. There are many different chemotherapy drugs. Some are given as tablets or capsules but most are given by drip (infusion) into a vein. The drugs go into the bloodstream and travel throughout the body to treat the cancer cells wherever they are. Sometimes just one chemotherapy drug is used, but often a combination of two, three or more drugs is given.

Chemotherapy can cause side effects. The side effects will depend on which drug (or combination of drugs) is used. There are now very good ways of preventing or reducing the side effects of chemotherapy.

Some medications interact or react with other medications. Before beginning chemotherapy, you must provide us with a list of current medications, including dosage and directions. This list should include prescription drugs, over-the-counter medications, vitamins, supplements, laxatives, allergy preparations, pain relievers, etc

Other treatments
Other treatments can be used to cure or control a cancer. Monoclonal antibodies are drugs that can `recognise' and find specific cells in the body. These drugs can be designed to find a particular type of cancer cell, attach itself to them and destroy them. They can be used alone, or a radioactive molecule can be attached to a monoclonal antibody, which then delivers radiation directly to the cancer cells. Hormonal therapies work by altering the levels of particular hormones in the body. Some cancers depend on certain hormones in order to divide and grow. By altering the level of hormones in the body, or blocking the hormones from attaching to the cancer cells the cancer can be controlled.

Research is trying to see whether vaccines can be given to treat a cancer that has come back or has spread.

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Why does cancer comes back?
A cancerous tumour consists of cancer cells which have the ability to spread beyond the original site. They may spread to other organs in the body by travelling in the bloodstream or lymphatic system. When these cells reach a new area of the body they may go on dividing and form a new tumour, often referred to as a "secondary" or a "metastasis". These may or may not be detectable on the imaging scans. If left untreated they may invade and destroy surrounding tissues.

How Does Chemotherapy Work?
Chemotherapy works by destroying rapid growing cells or by stopping cells from growing or multiplying. As the drugs are carried in the blood, they can reach cancer cells anywhere in the body but are also taken up by healthy cells. Healthy cells can repair the damage caused by chemotherapy but cancer cells cannot and so they eventually die. Unfortunately, as the chemotherapy drugs can also affect some of the healthy cells in your body, they can cause unpleasant side effects. However, damage to the healthy cells is usually temporary and most side effects will disappear once the treatment is over.

How is chemotherapy given?

Chemotherapy is carefully planned and is usually given as a series of sessions of treatment. Each session is followed by a rest period. The session of chemotherapy and the rest period is known as a cycle of treatment. A series of cycles makes up a course of treatment. Each session of chemotherapy destroys more of the cancer cells, but the rest period allows the normal cells and tissues to recover.

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There are four ways of giving chemotherapy drugs directly into the vein. These are through a:

• Cannula – a small tube inserted into a vein in your arm or the back of your hand.
• Central line – a thin, flexible tube inserted through the skin of the chest into a vein near the heart.
• PICC line (a peripherally inserted central catheter) – a thin flexible tube passed into a vein in the crook of the arm and threaded through until the end of the tube lies in a vein near the heart.
• Implantable port (also called a portacath) – a thin, soft plastic tube that is put into a vein. It has an opening ( port) just under the skin on your chest or arm.

The nurse or doctor will put a short, thin tube ( cannula) into a vein in the back of your hand or your forearm. You may find this uncomfortable or a little painful but it should not take long and the pain soon wears off. Once the cannula has been put in, it will be taped securely to keep it in place.

The chemotherapy can then be given through the cannula. Some chemotherapy drugs are diluted in a drip bag and the drip is attached to the cannula. This can take from 20 minutes to several hours, or sometimes days. If you feel any discomfort or notice a change in sensation, redness or swelling around the area of the cannula (or along your arm) while the drug is being given, let your nurse or doctor know immediately.

Central lines (tunnelled central venous cathers)

A central line is a long, thin plastic tube put into a vein in your chest. Hickman®* or Groshong®* lines are common types. The doctor or chemotherapy nurse will explain the procedure to you. You will be given a general or local anaesthetic before the central line is put in.

A central line

1. Central line is inserted into your chest
2. The line is tunnelled under your skin

Once it is in place, the central line is either stitched or taped firmly to your chest to prevent it being pulled out of the vein. It can stay in the vein for many months and means that you do not have to have cannulas put in when you have your intravenous chemotherapy. Blood can also be taken from this line for testing. You will be able to bathe or shower; although you should prevent water from getting to the area where the tube enters the skin – a plastic dressing can be used for this. There are very few restrictions to everyday life. Before you go home, make sure you are confident about looking after your central line.

Possible problems with central lines Two potential problems with central lines are blockage and infection. Once or twice a week the line has to be flushed with heparin, a drug which prevents clotting. The nurses on the ward can teach you how to do this or can arrange for a nurse to visit your home and do this for you.

If you notice any reddening, darkening or soreness of the skin around the central line, or if you have a high temperature, let your doctor know, as it could be a sign that you have an infection in the line. If this happens you will need to have antibiotics through the line to clear the infection.

Most hospitals consider a temperature above 38ºC (100.5ºF) to be high.

Your doctor may ask you to have a long, thin tube put into a vein in the crook of your arm. This is called a peripherally inserted central venous catheter (PICC). Your doctor or chemotherapy nurse will explain the procedure to you. You will be given a local anaesthetic before the line is put in.

Once it is in place, the PICC line is taped firmly to your arm to prevent it being pulled out of the vein. It can stay in the vein for many months. As with the central line it means that you do not have to have cannulas put in when you have your intravenous chemotherapy. Blood can also be taken through the line for testing. You will be able to bend your arm, bathe and shower, although you should avoid getting water on the area around the tube - a plastic dressing can be used for this. There are very few restrictions to everyday life. Before you go home, make sure that you are confident about looking after your line. A nurse can flush your line and change the dressing, or a friend or relative can be taught to do this for you.

The possible problems are the same as for central lines: blockage and infection.

The tube is threaded through the vein until the end is near to your heart

The end of the tube comes out just below the crook of your elbow

An implantable port is a thin, soft plastic tube that is put into a vein and ends in an opening ( port) just under the skin on your chest or arm. The port has a thin rubber disc through which needles can be passed to give medicines into the vein or take blood.

The tube is a long, thin hollow tube known as a catheter and the port is a disc about 2.5 to 4 cm in diameter. The catheter is usually inserted ( tunnelled) under the skin of your chest. The tip of the catheter lies in a large vein just above your heart and the other end connects with the port which sits under the skin on your upper chest. The port shows as a small bump underneath the skin which can be felt, but nothing shows on the outside of your body. The possible problems are the same as for central lines: blockage and infection.

Infusion pumps may be used to give some types of chemotherapy. There are various types of portable pump. These give a controlled amount of chemotherapy into the bloodstream over a period of time (from a few days to a few weeks). The pump is connected to a central line or a PICC line. This means that you can go home with the pump and so you need fewer visits to infusion center. The pumps are small enough to fit into a pocket and can be carried in a bag or belt holster.

The chemotherapy drugs are prepared at the infusion center. You, and perhaps a family member or friend, will be taught how to look after the pump. Some pumps are battery-operated and care has to be taken not to get them wet when you are washing. Your nurse or pharmacy staff will give you full instructions.

Where is Treatment Given?
Where chemotherapy is given depends on your general condition and the type of drug being used. Treatment may be given in our office or in the hospital.

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How Frequently is Treatment Given?
The length and frequency of treatment depends on the type of disease, goals of treatment, drugs used and how the body responds to the drugs. Treatment can be as frequent as every day, or on a weekly or monthly basis, depending on the physician’s orders.

What Determines How Well Treatment is Working?
There are several ways to determine how well your treatment is working. These include, but are not limited to the physical exam, radiology reports and laboratory testing.

How is Chemotherapy Used with Other Forms of Treatment?
Chemotherapy may be used in conjunction with surgery, radiation therapy and/or immunotherapy to: Shrink a tumor before surgery or radiation therapy. This is called neo-adjuvant therapy
Help destroy any cancer cells that may remain after surgery and/or radiation therapy. This is called adjuvant chemotherapy.

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SIDE EFFECTS OF CHEMOTHERAPY

Different chemotherapy drugs cause different side effects, and some people may have very few. Cancer treatments cause different reactions in different people and any reaction can vary from treatment to treatment. It may be helpful to remember that almost all side effects are only short-term and will gradually disappear once the treatment has stopped.

The main areas of your body that may be affected by chemotherapy are those where normal cells rapidly divide and grow, such as the lining of your mouth, the digestive system, your skin, hair and bone marrow (the spongy material that fills the bones and produces new blood cells).

If you want to know more about the side effects that may be caused by your chemotherapy treatment you should ask your doctor or chemotherapy nurse, as they will know the exact drugs you are taking. Although the side effects of chemotherapy can be unpleasant, they need to be weighed against the benefits of the treatment. However, if you find that the treatment or its side effects are making you unwell, you should tell your doctor or chemotherapy nurse. You may be able to have medicines to help you, or changes can be made to your treatment to lessen any side effects.

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• Tiredness
• Nausea and vomiting
• Hair loss 
• Loss of taste
• Constipation
• Neutropenia
• Mouth sores
• Diarrhea
• Anemia
• Loss of sexual desire

Tiredness
While having chemotherapy, and for some time afterwards, you may feel very tired and have a general feeling of weakness. It is important to allow yourself plenty of time to rest. The tiredness will ease off gradually once the chemotherapy has ended, but some people find that they still feel tired for a year or more afterwards

.Nausea and Vomiting
Some, but not all, chemotherapy drugs can cause nausea and vomiting. Many people have no sickness, as there are now very effective treatments to prevent and control it. It is much less of a problem than it was in the past. If you feel sick, it may start from a few minutes to several hours after the chemotherapy is given, depending on the drugs you are having. The sickness may last for a few hours or, rarely, for several days. HELPFUL HINTS – NAUSEA AND VOMITING
The good news is that very successful anti-nausea and anti-vomiting drugs are available. Your doctor will find the right drug for you to reduce this side effect.

• Avoid eating or preparing food when you feel sick
• Avoid fried foods, fatty foods or foods with a strong smell
• Eat cold or warm food if the smell of hot food makes you feel sick
• Eat several small snacks and meals each day and chew the food well
• Peppermints or peppermint tea may help
• Have a small meal a few hours before treatment, but don't eat just before treatment
• Drink plenty of liquid slowly, taking lots of small sips
• Ginger, either as ginger biscuits or ginger beer can reduce feelings of sickness
• Avoid filling your stomach with fluid before you eat .

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• Shorter haircuts make your hair look thicker and fuller and may make hair loss easier to manage if it occurs. 
• Use gentle hair products
• Avoid perming or colouring your hair if it is brittle or if your scalp is dry and itchy.
• Try not to brush or comb your hair too roughly – use a soft or baby's brush
• Avoid using hair dryers, curling tongs and curlers. Pat your hair dry gently after washing it
• Ask you physician for a prescription for a “cranial prosthesis”. The cost of the wig may be partially covered by your health insurance. 
• You may like to wear a hat or scarf when you go out. There are also turbans which can be worn in the house

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Change in taste

HELPFUL HINTS – CHANGE IN TASTE

• Eat only the foods that you like and ignore those that do not appeal to you
• Use seasonings and herbs to flavour your cooking
• Try marinating food, or using strongly flavoured sauces to go with food
• Sharp-tasting foods such as fresh fruit are refreshing and leave a pleasant taste in the mouth
• Some people find that cold foods taste better than hot foods

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HELPFUL HINTS – CONSTIPATION

• Drink plenty of fluids, as much as 8-10 glasses a day if you do not have renal or heart disease. Warm and hot fluids can be more helpful.
• Eat foods with a high fiber content – fruits, green leafy vegetables, whole grain cereals, bread, bran, raisins, currants, prunes, figs and dates, for example.

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• Call your doctor immediately if you develop temperature above 100.5F
• Be aware of your blood cell counts when your doctor checks them.
• Wash your hands frequently.
• Avoid crowded places. 
• Stay away from anyone who has a cold or the flu
• Stay away from children who have just been immunized. 
• Don’t get immunized yourself unless your doctor says it’s okay. 
• Use an electric shaver instead of a razor

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• Ask your doctor if there is anything you can apply directly to the sores or to prescribe a medicine you can use to ease the pain.
• Eat foods cold or at room temperature. Hot and warm foods can irritate a tender mouth and throat.
• Eat soft, soothing foods, such as ice cream, milkshakes, baby food, soft fruits (bananas and applesauce), mashed potatoes, cooked cereals, soft-boiled or scrambled eggs, yogurt, cottage cheese, macaroni and cheese, custards, puddings, and gelatin. You also can puree cooked foods in the blender to make them smoother and easier to eat.
• Avoid irritating, acidic foods and juices, such as tomato and citrus (orange, grapefruit, and lemon); spicy or salty foods; and rough or coarse foods such as raw vegetables, granola, popcorn, and toast.

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What is the Reason for a Bone Marrow Biopsy?
Most patients with a blood problem will have to have a bone marrow test at some time in their illness. This may be to make the diagnosis or to see how their disease is responding to the treatment. It is a test that allows your doctor to examine the bone marrow - the part of the body that makes all the blood cells in your body.

How is the Procedure Performed?
A bone marrow biopsy is an outpatient procedure usually performed in our office.

First, an area on your back is cleaned and injected with local anaesthetic. After the area is numb, a needle is inserted into the iliac crest (hip bone) to take a sample of bone marrow. After the pocedure, a dressing is placed on the site and, following a short observation period, you are able to return home. 

A most important question is whether it hurts. This will vary from patient to patient. Your doctor will always use lots of local anaesthetic to numb the skin, fat and the surface of the bone underneath. This should numb that area, pretty much like going to the dentist. The bone itself is harder to anaesthetise but usually most people feel little more than a tugging as the marrow is sucked out and a pressure at the pushing of the needle.

Although the procedure itself takes only about 30 minutes, you can expect to be in the office about one hour, including time for pre-medication, the actual procedure and post procedure observation. 

You must have someone drive you home.

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