Robert Stern

Even before Chris Irwin learned that a painless lump on his neck was stage 4 head and neck cancer he worked to stay in good shape. He exercised almost daily and paid reasonable, though not obsessive, attention to nutrition.

Since 2012, when Irwin faced an intense six-month regimen of almost daily radiation and weekly chemotherapy that wiped out his cancer, working out has taken on even more importance. Now 52, Irwin performs a range of physical activities, including weight training and swimming.

“The day after I had my feeding tube inserted, I went and ran five miles because I was determined to not let it stop me,” he says. “When my wife at the time saw me running, she cried because she couldn’t believe how strong I was trying to be.”

Irwin relied on the feeding tube for about three months because swallowing became unbearably painful, he says. Since then, his dietary choices have become even more deliberate. He now shuns fast food; packs his diet with berries, almonds, walnuts, garlic and honey; and opts for fish and chicken over red meat.

Irwin is one of an estimated 16.9 million cancer survivors living in the United States, according to the National Cancer Institute. That population is projected to increase almost 30 percent to 21.7 million over the next decade.

Patients with cancer and survivors generally can enhance their well-being and lower health risks by making the twin pillars of a nutritious diet and regular exercise part of their lifestyle, experts say.

“One is just as important as the other,” says Lidia Schapira, M.D., director of the cancer survivorship program at the Stanford Cancer Institute and an associate professor of medicine at the Stanford University Medical School. “The big picture is that, for people living with cancer (and) for cancer survivors, exercise and nutrition really matter.”

Eating foods rich in nutrients, such as protein, carbohydrates, vitamins and minerals, along with drinking plenty of water, can help people maintain a healthy weight, increase energy and strength, heal faster and feel better overall.

Physical activity has benefits, too. It improves heart health, boosts muscle strength and endurance, and reduces anxiety and fatigue, according to the American Society of Clinical Oncology’s patient website, Cancer.Net, for which Schapira serves as editor-in-chief.

Patients who exercised after any cancer diagnosis had a lower relative risk of cancer mortality and recurrence compared with those who exercised less or not at all, according to the results of a 2017 study in Epidemiologic Reviews. The findings also showed that patients who stayed or became more physically active were likely to face fewer or less severe side effects from treatment than less active or inactive patients.

For Irwin, the value of exercising after cancer made sense instinctively. “Our bodies were not made to be sedentary. They were made to move,” says Irwin, who lives in California, where he works as director of operations for a security company. His varied regimen also includes squat thrusts, a Philippine martial art and — his most recent addition &mdash; yoga. He works out 25 to 90 minutes daily, five or six times a week.

Survivors should aim for 150 minutes of exercise each week, including strength training on at least two days, according to the American Cancer Society, which also recommends that survivors talk with their care team about a suitable exercise plan.

For survivors who feel a lack of stamina and strength after a prolonged period of inactivity, the American Society of Clinical Oncology recommends a daily 10-minute walk to kick-start the exercise habit. People also can turn everyday activities and chores into exercise opportunities, such as taking stairs whenever possible, running errands on foot or

It may help to consult a certified health and fitness professional. The American College of Sports Medicine is a good resource for finding one certified as a cancer exercise trainer.

Ideally, an exercise program for survivors should hit on four broad areas: strength, cardiovascular health, range of motion and flexibility and balance, says Andrea Leonard, a certified personal trainer and founder and president of the Portland, Oregon-based Cancer Exercise Training Institute. “The variables are how much, how often and how intense,” she says. Leonard, 53, is a 35-year thyroid cancer survivor who has had 23 close relatives receive cancer diagnoses, including both parents.

She recommends exercises that improve balance to help survivors address neuropathy-related problems. A basic balance exercise starts off with both feet on the ground and hands on a counter or the back of a sturdy chair for support, then raising one foot off the floor at a time. If that is easy, try standing with one foot raised without holding on to the chair or counter, she says. For a more challenging balance exercise, move one leg to the front, side and back while balancing on the other leg.

Cardiovascular workouts can strengthen the heart and lungs, which may be weakened by chemotherapy and radiation. These include walking, climbing stairs, dancing and riding a stationary bike, as well as swimming if the person’s immune system is not compromised and there is no skin irritation from radiation, Leonard says. Strength training can bolster bones made fragile by treatment-related osteoporosis.

“Shoot to exercise until you feel mild discomfort but never pain. Pain is not a good sign,” Leonard says. However, she adds, there is no cookie-cutter plan for exercising after a diagnosis, because each person has a unique mix of health history, type and stage of cancer, fitness level and response to treatment.

A plant-based — but not necessarily vegetarian &mdash; diet can help survivors rebuild strength after treatment and reduce their risk of other chronic health problems, such as obesity, heart disease and diabetes, Schapira says.

“Choose a diet rich in vegetables, whole grains, fruits and beans,” says Kate Allen, RDN, LDN, an outpatient clinical dietitian at Moffitt Cancer Center in Tampa, Florida. “Choose the whole forms of foods as much as possible. Aim for variety, bright color (and) strong flavors on your plate for the benefits of phytonutrients, which are naturally occurring plant chemicals that have possible anti-cancer benefits.”

Limit red meat, including beef, pork and lamb, to 18 ounces or less a week, and avoid regular consumption of processed meat, such as bacon and hot dogs, recommends the American Institute for Cancer Research. The latest research findings show that exceeding 18 ounces of red meat weekly increases the risk of colorectal cancers, according to the institute. Likewise, stomach and colorectal cancer risks rise with regularly eating any amount of processed meat, which is preserved by smoking, salting, curing or adding other preservatives.

Avoid processed foods with added salt or foods preserved with salt, says Allen, whose advice reflects the institute’s guidelines. She also advises survivors to steer clear of foods that are high in empty calories and lead to weight gain. These can include sugary beverages and sugar-added foods, refined starchy foods and fast food.

A tailored diet will also ease treatment-related side effects. For example, diarrhea can be mitigated with a low-fiber diet, Allen says, and small, frequent meals might be easier to handle for patients who feel full after eating a small amount of food or have nausea and fatigue.

Paying new or renewed attention to diet and exercise can help survivors regain the sense of control that a cancer diagnosis often steals, Schapira says. That benefit is an easily overlooked but important aspect of improving physical and mental health.

Kate Beland can attest to that — exercise plays a major role in her life as a cancer survivor. “It’s a sense of control in a very uncontrollable situation, and for me, that was huge,” says Beland, a runner, skier and writer.

The 44-year-old married mother of three received a diagnosis of stage 3 melanoma of her hip in April 2015, one week after she ran the Boston Marathon for her first and only time. Cancer also developed in two lymph nodes in her groin; two successful surgeries removed it all. Beland, who lives in Portsmouth, New Hampshire, and once managed a health club, says that resuming physical activity fairly early in her recovery was slow going at first but helped control the swelling she experienced as a side effect of her lymphadenectomy, a surgical procedure to remove lymph nodes.

Because of her lymphedema, she is more conscientious about cutting back on breads and processed starches, staying hydrated and having a mix of plant-based foods and protein in her meals. Beland runs or strength trains five or six days a week. On winter weekends, she skis with her family. She spends a little more time stretching and clearing her head than she did before her surgery. “Physically, I needed to be active and to do everything just to get my mobility back and heal my body,” Beland says. “But mentally, it would have been a lot harder. Running was the tool I needed to cope. It was like going to church for me.”

Of course, not every survivor is a runner. Carlene Igras’ go-to exercise is a brisk walk. A retired middle-school teacher, Igras had a hysterectomy and six chemotherapy rounds over four months in 2017 after learning that March that she had stage 1A ovarian cancer. “I was always a really healthy person, so this kind of knocked me back,” says Igras, 63. To rebound, she makes a point of going for daily 30-minute power walks, even in the tropical heat of summer in her adopted hometown of Vero Beach, Florida.

She says walking even during treatment helped minimize the fatigue that chemotherapy brought on. Recently, she started doing yoga at home, aiming for three sessions a week. She cut out fast food, junk food and fried and greasy food. “Your whole mindset changes when this kind of thing happens to you,” Igras says. “It’s like, what can I do to try to keep my body healthy?”

KATE BELAND combines plant-based foods and protein in her meals. She tries to exercise at least five days a week.

Articles

Survivors find that physical activity and sound nutrition lower health risks and boost well-being.

Taking Back Control: Exercise and Nutrition Boost Survivor Well-Being

A child’s skin is thinner than an adult’s, and thus more sensitive to the sun’s damaging ultraviolet (UV) radiation, according to the World Health Organization, and children who get a lot of sun and sunburns can expect to face higher rates of melanoma as adults. Yet, because children tend to spend more time playing outdoors, most people get the majority of their sun exposure before they reach age 18.

So what should be done to protect children from the sun’s harmful rays? The same multi-pronged approach that experts recommend for adults.

That means covering up with protective clothing, a broad-brimmed hat and UV-filtering sunglasses; avoiding outdoor activity during the midday hours when UV radiation is most intense; seeking shade; avoiding tanning beds and sunlamps; and using a broad-spectrum sunscreen with a sun-protection factor (SPF) of at least 15.

The WHO emphasizes that sunscreen should never be used to prolong the duration of sun exposure, but rather as a routine complement to other safeguards.

Here are some key tips to keep in mind when it comes to sunscreen and children:

Sunscreen and other UV-protection measures should be put in place for any outdoor activity, even on overcast days, because most UV radiation penetrates clouds and glass.

Many surfaces, such as snow, sand and water, reflect the sun’s rays and magnify UV exposure.

For sensitive areas of the body, like the nose, cheeks, tops of the ears and shoulders, the American Academy of Pediatrics recommends applying a mineral-based sunscreen instead of a chemical-based sunscreen to avoid possible allergic skin reactions or mild hormonal interference. Mineral-based sunscreens are made with zinc oxide or titanium oxide, though some also have chemical filters as active ingredients, so read the label carefully.

Avoid the chemical filter oxybenzone in children’s sunscreen, if possible, because of concerns about mild hormonal properties. A sunscreen with oxybenzone, however, is still better than no sunscreen at all, because sunburns are dangerous and could lead to skin cancer later in life.

Put sunscreen on 15 to 30 minutes before going outdoors and reapply at least every two hours and after swimming, sweating or drying off with a towel.

For babies younger than 6 months, avoid using sunscreen without the advice of a doctor. Instead, keep babies that young covered up well and out of direct sunlight as much as possible.

If sunscreen use for babies is necessary, apply it only on small areas of the body, like the face.

Avoid using spray sunscreen that might accidentally get inhaled.

What should be done to protect children from the sun's harmful rays? The same multi-pronged approach that experts recommend for adults.

Thin Skin: Children Need Special Protection From the Sun's Damaging Rays

Kerrie Taber wasn’t a sun worshipper when she was growing up, and she’s definitely not one now, three-and-a-half years after being diagnosed with skin cancer’s deadliest form, melanoma.

But she did spend much of her summer during her Ohio childhood in her family’s backyard pool and, during soccer season, outdoors on the field perfecting her game.

Neither she nor her parents worried about the risks of unprotected sun exposure.

“We didn’t use sunscreen. Getting burned, et cetera, just wasn’t on our radar” of things to worry about, says Taber, a college professor at the University of Arkansas, Fort Smith, who lives in Arkoma, Oklahoma.

Taber, 44, had plenty of unfiltered time in the sun over the years, including her fair share of memorable childhood sunburns.

Doctors can’t say for sure how much of a role cumulative and intermittent exposure to the sun’s ultraviolet (UV) rays or her early sunburn history played in Taber developing melanoma, although chances are high that they were factors.

Research suggests that UV light from the sun and other sources like tanning beds figures into almost 90 percent of melanoma cases, according to the Melanoma Research Foundation.

Genetics and a family history of skin cancer also make some people more susceptible to melanoma than others. Still, the strong link between UV exposure and melanoma, as well as other, more common but less aggressive forms of skin cancer, explains why dermatologists strongly advise people to take some simple, common-sense steps to protect themselves from UV light.

The American Academy of Dermatology (AAD) emphasizes that anyone can develop melanoma, regardless of race or skin complexion. Therefore, everyone should take preventive measures against UV exposure, despite the fact that genetics and heredity are also believed to be risk factors.

These measures include limiting outdoor activity from 10 a.m. to 2 p.m., when the sun’s rays are most intense; seeking shade; and wearing broad-brimmed hats, long-sleeved shirts, pants and sunglasses.

Also, it’s wise to avoid tanning beds and sun lamps, because they rely on UV light, which can harm the skin and have been shown in numerous studies to increase melanoma risk, especially in long-term users who start tanning before age 35.

“Each time you tan, you are undergoing DNA damage,” says Steven Wang, director of dermatologic surgery and dermatology at Memorial Sloan Kettering Cancer Center in Basking Ridge, New Jersey.

To protect the skin, using the right type of sunscreen on a regular basis should be part of almost everyone’s UV-protection plan. The exception to the rule are babies 6 months old and younger. Their highly sensitive skin and higher surface-area-to-body-weight ratio make their exposure to the chemicals in sunscreen greater than that in older children and adults. The best way to protect babies from the sun is to keep them in the shade. If that is impossible, check with a doctor about how to apply sunscreen safely.

The rest of us should remember to use sunscreen even on cloudy, rainy and snowy days. That’s because the majority of the sun’s UV light, known as UVA, penetrates through clouds and even glass not treated with a UV filter.

Although there isn’t a broad range of long-term scientific studies on the benefits of sunscreen use in reducing the risk of developing melanoma, one landmark study found a dramatic correlation between daily sunscreen use and a substantially lowered incidence of the disease.

 The randomized study, conducted in Australia over a 10-year period and published in the Journal of Clinical Oncology in 2011, found that the number of new melanoma cases at the end of the trial period was twice as high among participants instructed to use sunscreen the way they always had as in the group told to use sunscreen daily. Eleven melanomas developed in the control group, compared with 22 melanomas in the daily-sunscreen group. There were 1,600 people in the study.

In addition, there were nearly four times more severe, invasive melanoma cases in the group that didn’t use sunscreen daily (11 invasive tumors) than in the group that did (three invasive tumors).

For people like Taber, who is fair-skinned and has more than 50 moles speckling her skin — many of them unusual, but at the moment not suspected to be cancerous &mdash; using sunscreen and other preventive measures is particularly important.

That’s because her skin type and the number and nature of her moles make her more likely than the general population to develop melanoma in the first place, and the risk of recurrent melanoma is high, according to the AAD.

When it comes to sunscreen, experts advise focusing on several key elements.

One, look for a sunscreen with an SPF (sun-protection factor) of at least 30 and apply it to all exposed skin.

The SPF number refers to the percentage of the sun’s UV radiation the sunscreen blocks or absorbs, and has nothing to do with how long one application of the sunscreen will remain effective. An SPF 30 sunscreen works against 97 percent of UV radiation and those with higher SPF ratings are effective against slightly more, although no sunscreen is 100 percent effective.

Two, apply sunscreen 15 to 30 minutes before venturing into the sun, and reapply every two hours or as frequently as directed on the label.

Three, even if a sunscreen claims to be water-resistant, be sure to apply it every two hours, especially if you’re swimming or sweating a lot.

And four, make sure the sunscreen is labeled broad-spectrum, which means that it blocks both UVA and UVB light.

Both kinds of UV radiation damage the skin and have been deemed as human carcinogens by the World Health Organization and the U.S. government’s National Toxicology Program.

UVA rays, which have longer wavelengths than UVB rays, account for as much as 95 percent of the sun’s UV radiation that reaches the earth’s surface.

Due to its longer wavelengths, UVA radiation penetrates into deeper layers of the skin and has long been suspected of playing a major part in skin aging and wrinkling.

Recent studies also strongly suggest that UVA radiation can trigger and accelerate the development of skin cancers, according to the Skin Cancer Foundation.

UVB rays are responsible for burning and tanning, and they, unlike UVA rays, don’t penetrate glass and vary in intensity by season, location and time of day, with the highest concentration of UVB rays between 10 a.m. and 4 p.m. from April through October in the United States.

While it’s important to be aware of the harm that UV radiation can do and to take the proper precautions, that shouldn’t mean becoming fearful of the sun to the point of shunning it entirely.

 “When we talk about appropriate photoprotection (protection from UV light), I want to emphasize that we all should continue to participate in outdoor activities because psychologically, physically, it’s good for all of us,” says Henry Lim, chair of dermatology at Henry Ford Hospital in Detroit. “But put a photoprotection package (in place), protecting the skin from damaging effects of the sun.”

In terms of sunscreen, as long as it’s got an SPF of 30 or higher and is broad-spectrum, the specific formulation is up to the individual.

The key thing for most people to consider is simply whether the sunscreen, be it a lotion, gel, cream or stick, is a product the user feels comfortable wearing so it will be used routinely, rather than sit forgotten in a cabinet or the bottom of a purse, experts say.

Yet people may want to think twice before using a spray. In June 2015, the U.S. Food and Drug Administration (FDA) announced that it was planning on studying spray products because of concerns about ineffective coverage and potentially harmful chemicals that could affect the lungs.

Despite our knowledge about the importance of adequate SPF levels, according to Wang of Memorial Sloan Kettering, “You’re better off picking even a broadspectrum SPF-15 sunscreen if you will use it regularly than buying a high-SPF sunscreen that ends up getting no use because you don’t quite like it.” But there is a caveat to this advice. People who are going to be out in the sun for extended periods or have had melanoma or another skin cancer should make use of a broad-spectrum sunscreen of SPF 50 or higher and reapply every two hours.

Sunscreen Ingredients: Upsides and Downsides

“The most important thing those individuals can do is try to avoid an extensive amount of UV exposure. Find shade, wear protective clothing and hats,” he says.

The FDA has approved 17 active ingredients for sunscreen. They fall into two categories: chemical and mineral filters.

The most common sunscreens on the U.S. market contain chemical filters, which typically include a combination of two to six of the following active ingredients: oxybenzone, avobenzone, octisalate, octocrylene, homosalate and octinoxate. Mineral sunscreens use zinc oxide, titanium oxide or a combination of the two as UV blockers. There are also numerous sunscreens that synergize a combination of mineral and chemical buffers to protect users from UV damage.

Although all sunscreen formulations available for sale in the United States are considered over-the-counter drugs and are regulated by the FDA, there are advantages and disadvantages to both the chemical and mineral filters.

The chemical, or organic, varieties tend to be less visible on the skin once applied than their mineral, or inorganic, counterparts, which can leave a whitish stain, especially on darker-toned skin, until the sunscreen is rinsed away, Lim says.

So, cosmetically, the mineral-based sunscreens might be less appealing for some people.

On the other hand, mineral-based sunscreens almost never penetrate the skin and, in recent years, have had micronized formulations of their active ingredients that make them less conspicuous when applied than they have been in the past.

Chemical sunscreens are more likely than their inorganic counterparts to penetrate the skin, and some ingredients used in these sunscreens have been detected in mother’s milk, linked to hormonal interference and correlated to elevated rates of skin allergies, according to the Washington, D.C.- based environmental-health watchdog organization Environmental Working Group.

Nevertheless, both the FDA and leading dermatologists like Lim consider available broad-spectrum sunscreens, whether chemical or mineral in nature, to be safe and effective instruments against UV damage.

Still, the products available on the U.S. sunscreen market are less innovative than their counterparts in Europe and elsewhere. In fact, the FDA has not approved a new active ingredient for over-the-counter sunscreen use since the 1990s.

 Eight new sunscreen-ingredient applications have been filed with the FDA for general over-the-counter approval since 2002. Many of these products have been widely used for a decade or more in other parts of the world — but have yet to get the green light for general use in the United States.

Last December, President Obama signed the Sunscreen Innovation Act into law with the aim of getting the FDA to act on new sunscreen applications in a timely manner.

In response, the FDA told manufacturers it needs more data about all eight of the ingredients submitted for its review before it can approve them as generally safe and effective for their intended use in sunscreens.

For now, the American public will have to continue relying on the existing FDA-approved sunscreens.

Clothing for Protection, Skin Exams for Detection

“The stuff that we have now is good, but we can do better,” says Tim Turnham, executive director of the Melanoma Research Foundation. “We need more options.”

In general, darker clothing and synthetic fabrics, such as nylon or polyester, and those with tighter weaves, like denim, offer a higher level of UV protection than more loosely woven, lighter-colored fabrics like cotton T-shirts.

And while all fabric filters UV radiation to some degree, some clothing is manufactured specifically to absorb or reflect UV radiation and rated with an ultraviolet protection factor (UPF) value. Apparel with a UPF of 40 or greater provides excellent protection, blocking 97.5 percent of UV radiation or more.

Having some UPF-rated clothing on hand is worthwhile, especially for people with a personal or family history of skin cancer or those with higher risk factors for its development, such as fair skin, blue eyes, red hair or a large number of moles.

Another easy way to protect yourself from melanoma is by conducting monthly 10-minute self-examinations for changes to your skin. This practice should be a routine for everyone, according to the Skin Cancer Foundation.

Examine your face, thoroughly inspect your scalp (with assistance from a friend or family member), your whole body, front and back, and even between your fingers and under the fingernails for changing or unusual-looking moles and lesions.

Make a simple map of your body, front and back, pinpointing the location of existing moles and markings so you can easily recognize new ones in future exams.

It might be worthwhile to have your first exam conducted by your doctor so he or she can help you identify potential trouble spots to watch. For those who already have known sun damage, or a history of melanoma or atypical nevi, special examinations by a dermatologist may be needed regularly.

Due to her melanoma history, Taber says she is vigilant these days about getting regular skin exams from her dermatologist and shielding herself from UV exposure.

She uses an SPF-50 sunscreen daily that is marketed for babies because it is fragrance-free and doesn’t sting her eyes.

But she doesn’t sacrifice her cherished outdoor time, which she values because she is in a running club and also regularly participates in 100- to 150-mile bicycle treks.

Still, she says, her brush with melanoma has altered her day-to-day life.

“You kind of change the way you look at things,” she says. “I’m trying to bring awareness to people within my scope. If I can help one person catch it before it becomes melanoma, then it’s good. I can make a difference.” 

Using sunscreen and protective clothing are good preventive measures.

Beware the Beating Sun: Unprotected Sun Exposure Increases Risk of Skin Cancer

Nikki Mann knows first-hand that it takes patience, diligence and teamwork to help a loved one recover from a stem-cell transplant following a blood cancer diagnosis.

Her husband, Bill Mann, successfully underwent a stem-cell transplant in 2004, four years after he was diagnosed with multiple myeloma at the age of 45.

Although the transplant was uncharted territory for the Manns, Nikki’s role as caregiver had already been cemented through their initial years of his cancer saga. This time, they both had to be mindful of the heightened risk for infection in the ensuing days and weeks, because a stem-cell recipient’s immune system is weakened for a period of time after a transplant.

From an infection standpoint, the main risks are viral and fungal infections, but some bacterial infection risk is present too, particularly for patients whose treatment regimen relies on intravenous catheters that stay implanted for months at a time, says medical oncologist Ravi Vij, a specialist in bone marrow/stem cell transplants at the Siteman Cancer Center at the Washington University School of Medicine in St. Louis, Mo.

After Bill Mann underwent a stem cell transplant to treat his multiple myeloma, his wife, Nikki Mann, helped him avoid infection. [Photo by Reg Campbell]

The danger from many infections when a patient’s immune system is underperforming post-transplant, he says, is that they could turn lethal if untreated once symptoms emerge.

The Manns felt prepared to ward off such infections.

“We had four years of chemo and (radiation) therapy before the transplant, so this was like the next step,” says Nikki, a merchandiser sales associate with a real estate brokerage.

Bill’s transplant followed not only extensive chemotherapy and radiation treatments, but surgery to fuse vertebrae in his lower spine, which had been on the brink of collapse because of a blood-cell tumor there known as a plasmacytoma.

The transplant was necessary to boost his bone marrow’s ability to generate new, healthy blood cells after the combination of the cancer and highdose therapies to treat it ravaged his body’s blood-cell replenishment system.

Bill underwent an autologous stemcell transplant, the more common of the two major categories of stem-cell transplants. In that kind of transplant, stem cells extracted from the patient’s own circulating blood are reintroduced into his bloodstream following intensive chemotherapy that would otherwise permanently disable the bone marrow’s blood-producing ability.

The procedure didn’t require any extended stay in the hospital for Bill, who is retired from the Air Force and is a former instruction design contractor for the military.

He and Nikki, 53, who live in San Antonio, Texas, went home the same day as the transplant — although experts say that post-transplant recovery time in the hospital varies by patient and institution and routinely can take two to three weeks.

After the transplant, the Manns were wary of the heightened risk for infection.

They say they feel fortunate to have dodged any major complications as a result of the transplant. There was just one instance that sent them back to the hospital, about a week after the transplant, because Bill had developed a fever of 101 Fahrenheit, and diarrhea.

With the exception of that one incident, “we were surprised that it didn’t affect him as much as we thought it would,” Nikki says.

To contend with the increased risk of infections in the first months after the transplant, they followed their medical team’s guidance and common sense.

Even before the transplant, they had their house’s air conditioning replaced because it was old and rather dirty and they didn’t want it to be the source of any problems posttransplant.

They took care to monitor Bill’s temperature regularly. They washed their hands thoroughly and frequently to counter the threat of bacterial infections. Bill wore a mask to minimize the risk of contracting a virus when they had to leave home for appointments.

They spoke with friends and family by phone instead of having guests over who might have a slight cold or some other bug. He steered clear of the cats’ litter box. He didn’t eat uncooked foods, which could have contained bacteria. She stayed on top of his prescribed medication schedule.

Bill, for a brief time, ceded yard work to Nikki to reduce his chances of developing a fungal infection from the soil. And Nikki kept their house clean and tidy.

Those measures are largely in keeping with steps transplant experts recommend, and may have been even slightly more rigorous than necessary.

For example, as long as other precautions are taken with visitors, such as making sure they aren’t sick and that they wash their hands adequately, there is no reason, from an infection-prevention standpoint, to forbid them from the patient’s home following a transplant, experts say.

“Listen to the physician’s recommendations from the transplant center. There is going to be some difference in policies and procedures from one center to another,” says Vij, who is also a professor of medicine at Washington University School of Medicine. “Patients whose relatives are sick should avoid, obviously, being close to them.”

He also advises patients to avoid construction areas, dust and mold, animal litter, which can contain bacteria or parasites, and soil in the short-term, post-transplant environment.

The duration of that short-term period of extra vigilance for infections due to a weakened immune system depends on the patient and the type of stem cell transplant.

The elevated risk for problems is usually lower and of a shorter duration for recipients of autologous transplants, like Bill Mann, than for those who get an allogeneic stem cell transplant, Vij says.

For the latter, a patient’s stem cells are replaced with new, healthy stem cells from a donor or from donated umbilical cord blood after chemotherapy alone or in combination with radiation therapy.

Because allogeneic transplants rely on someone else’s stem cells, the patient may have to be on steroids or immunosuppressive drugs for a prolonged period to prevent or minimize the severity of graft-versus-host disease, or GVHD, he says. GVHD is a complication that occurs, especially for allogeneic transplant recipients, when the donor’s blood cells attack the recipient’s body rather than defending against illness.

Symptoms of GVHD include abdominal pain, cramps, nausea, vomiting, diarrhea, a skin rash with itching and redness, or a rash with raised, discolored areas. Other symptoms are dry eyes or vision changes, dry mouth, fatigue, muscle weakness and chronic pain, weight loss, vaginal dryness, shortness of breath and joint pain or stiffness.

While that issue arises almost exclusively among allogeneic transplant recipients, there have been documented but extremely rare cases of GVHD in autologous stem-cell transplant patients also, Vij says.

Caregivers and patients should monitor for signs of GVHD in the days, weeks and months after a transplant, in addition to being vigilant for signs of infections, such as fever, diarrhea and skin rash, says Jeane M. Kuensting, a bone-marrow transplant nurse practitioner at the Siteman Cancer Center.

While the period of intense monitoring for complications can vary from one center to another, the rule of thumb at Siteman is that the first 100 days after a stem cell transplant are the most critical, Kuensting says. Aside from infection and GVHD symptoms, caregivers should be watchful for signs of fatigue in the wake of a transplant and of their own stresses and anxieties, she says.

“Patients can change clinically very quickly,” she says. “There’s a lot of emotional ups and downs with that.”

Caregivers also need to make sure the patient stays hydrated, gets enough nutrition and works to rebuild his or her strength by walking around regularly rather than just lying in bed around the clock, Kuensting says.

Due to their increased infection risk, stem-cell transplant patients may be prescribed preventive medication that they are instructed to take for several months to even a few years, especially after an allogeneic transplant, Vij notes. These preventative medications can aim to thwart viral infections, like shingles, as well as bacterial and fungal infections.

While allogeneic transplants tend to carry a greater share of potential complications and a longer recovery time, they also have a higher potential benefit because they aim to cure the patient of the cancer rather than just extend his life, Vij explains.

But not all blood-cancer patients can be treated with allogeneic transplants, he says.

Despite the need for extra vigilance against infections and other complications in the weeks and months after a transplant, patients and their caregivers can get carried away with worries.

“There are people who get so paranoid about infection that they put themselves in a bubble that can lead to both social and mental deterioration,” Vij says. “Our goal is ultimately to get the patients to be as normal as they can be in their daily activities.”

Some patients, especially autologous transplant recipients, even return to work within two or three weeks of their transplants. On the other hand, some don’t return to work at all, though that is more common for allogeneic transplant recipients, Vij says.

In Bill Mann’s case, he is no longer employed, though he says that is a function of the job market and not due to medical reasons.

He describes himself as his wife’s personal cook and bottle washer. Though he says there’s not really anything he can’t do now that he was able to do before his transplant, he doesn’t have as much energy as in the past.

“I can work and do something all day but I’ll pay for it the next day if I don’t pace it,” Bill says.

He gets computed tomography (CT) scans every six months to make sure new tumors haven’t surfaced, and he and Nikki do their best to keep their stresses and worries in check.

Partly to that end, they participate in a multiple myeloma support group through the Leukemia & Lymphoma Society (www.lls.org). Members — both patients and caregivers &mdash; share not only war stories but also plenty of humor arising from genuine bonds of friendship that they have formed, Bill says.

Another method of keeping worry under control is to take advantage of psychological counseling services that cancer treatment centers may offer. In fact, these can be a resource for both the patient and the caregiver, as is the case at Siteman Cancer Center.

“We have an oncology-psychology service … that’s even available for the caregiver as well,” Kuensting says.

Managing stress is important for any patient-caregiver relationship. But it has added significance for the Manns because, shortly after Bill’s cancer diagnosis, Nikki was diagnosed with multiple sclerosis.

Although her MS has not been debilitating, except for one episode early on, its symptoms flare up when she feels stressed out. They manifest themselves through pain in the back of her head, rapid fatigue and weakened legs from feeling overheated, she says.

Nikki says additional keys for her — and for other caregivers who want to fill that role well &mdash; include having good, open communication with your loved one, having friends and relatives outside the relationship who will let you vent and having a life outside the caregiving role.

She says she is grateful that her employer accommodated her schedule to let her look after Bill without forcing her out of her job.

“We were kind of like mini-hermits for a while. If I didn’t go to work, I probably would have gone nuts,” she says.

In addition to work, friends and the multiple myeloma support group, Nikki also sets time aside for quilting and reading.

She says it’s important — both for the patient and the caregiver &mdash; that the caregiver not feel bad about taking time to pursue activities that help him or her decompress.

“Don’t feel guilty,” Nikki says. Also, encourage the patient to look after himself or herself and engage in life as much as possible.

“Don’t make the person you’re taking care of an invalid,” she says. “If you do that, you’re going to have some problems.”

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