Teresa McUsic

The recently released Dietary Guidelines for Americans, 2010 make one thing clear: we should decrease our salt intake. For cancer patients, especially those already following a low sodium diet for heart health, the idea that they may need to increase their sodium intake can seem like a huge mental shift. Yet, certain cancers and their treatments can cause a reduction in the concentration of sodium in your body, a condition called hyponatremia.

Salt is important for maintaining blood pressure, keeping muscles and nerves working properly and regulating body fluid balance. Hyponatremia is a condition that results in an imbalance of the ratio of water to salt in body fluids outside of the cells.

The frequency of hyponatremia in cancer patients is unknown, but it is the most common electrolyte disorder in the U.S. A leading cause of the disorder is a condition called the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, which occurs when high levels of the antidiuretic hormone are produced and cause the body to retain water instead of excreting it through urination. SIADH accounts for approximately 30 percent of all cases of hyponatremia and affects up to 2 percent of the entire cancer population.

“In my patients going through cancer treatment, hyponatremia is somewhat prevalent,” says Stacy Kennedy, RD, a senior clinical nutritionist at the Dana-Farber Cancer Institute in Boston.

In my patients going through cancer treatment, hyponatremia is somewhat prevalent.

Several cancers can be associated with hyponatremia, says Linda Pataki, RD, a supervisor of clinical nutrition at M.D. Anderson Cancer Center in Houston. Among them are cancers of the head and neck, thyroid, kidneys, bladder, adrenal glands and gastrointestinal system, as well as cancers of the breast, skin, brain, prostate and gynecological system and various blood cancers. The highest occurrence of SIADH is in small-cell lung cancer, where it occurs in 11 percent to 46 percent of all cases.

Side effects from surgery, radiation and chemotherapy, including diarrhea and vomiting, may also cause hyponatremia, Kennedy says. The condition can also occur with many non—cancer-related situations that involve both fluid deficiency or excess, including intense, long-duration exercise, she adds. Congestive heart failure, kidney diseases, low thyroid function, eating disorders and certain pain medications, including morphine and barbiturates, may also bring it on, Pataki says.

Symptoms of hyponatremia include minor headaches, muscle cramps, fatigue, confusion, dizziness and seizures, Pataki says. Medical attention is not required for minor symptoms unless they become chronic or extreme, she adds.

If you’re in cancer treatment, hyponatremia will be spotted in the frequent blood tests that accompany treatment, Kennedy says. Narrowing down the many possible causes, including SIADH, typically requires additional blood and urine tests.

“If we see low sodium levels, we can minimize some of the symptoms,” she says. 

Hyponatremia can usually be corrected by simple dietary measures, the nutritionists say. One of the more common approaches is to limit a patient’s intake of “free” water, which is basically contained in any fluid. Replacing regular water with broth, coconut water or a sports drink will usually return sodium levels to normal, Kennedy says. Sometimes these remedies are added into intravenous fluids if a patient is not eating by mouth. Eating salty foods, such as pretzels, is another way to raise sodium levels quickly, Pataki adds. However, extra salt may not be the right approach if there is co-existent heart, liver or kidney disease, so it is important to make sure your doctor or dietitian formulates a specific plan for you.

If the sodium levels don’t change from dietary adjustments, hyponatremia can be treated medically, Pataki says. If limiting fluids does not regulate levels, antibiotics, such as Declomycin (demeclocycline) or the mood-stabilizing drug lithium, which affects the flow of sodium through the body, can be used for chronic hyponatremia. Once treatment is over, the body often returns to its normal sodium levels.

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Dietary modifications can improve low sodium levels caused by cancer. 

Pass the Salt

The words may stick in your throat, but telling the people in your life that you have cancer can trigger important benefits to your treatment.

“When diagnosed with cancer, you can feel very isolated, vulnerable and alone,” says Frances Baumgarten, PhD, clinical psychologist, president and co-founder of Fran's Place, the 

 in Newport Beach, Calif. “The enormous amount of emotion around the diagnosis, treatments and the future are unbearable if you don’t share your thoughts and feelings with loved ones. It is so important to have the love, strength and support of family and friends throughout the entire journey.”

Despite these needs, disclosure may not be easy, she says.

“No matter how much press there is about cancer, it is still very traumatizing to be told you have cancer,” she says. “There is so much information to absorb and so many emotions to manage that it can feel nearly impossible to find the words to tell your loved ones and friends. The words ‘I have cancer’ can cause so much anxiety, that they get stuck in your throat.”

Baumgarten herself, who was a psychologist for several years before her own diagnosis of stage 3 breast cancer in 1989, says she had trouble telling people.

“With all of my education, training and tools, I struggled with these words, too,” she says.

Baumgarten recommends telling at least one person, someone you can rely and depend on for support. “This will help wrap your brain around what’s happening,” she says. “Having a family member or friend say ‘I’m here for you’ feels really good.”

When to first disclose your diagnosis to others is a totally individual decision, she says. You can choose to let people know when there is a suspicion of cancer or well after the diagnosis is confirmed. You may choose to tell different people at different times, but having a plan on when, who and what information to disclose is helpful in the long run.

“Reach out when you feel comfortable reaching out,” she advises. “There is no right or wrong way to do this.”

At the same time, avoiding that discussion completely is not helping you process the information, she says.

“Every time you repeat the story, you get a better handle on it,” Baumgarten says. “Talking about details and emotions with partners and family is very important. It helps you feel like you have more control over the situation, brings everyone closer and enables you to deal with the cancer as a team.”

The simplest approach is often the best, says Mark Kantrowitz, a testicular cancer survivor who created the website 

 to provide practical guidance for cancer patients. Stick to the basic facts of your type of cancer, stage, treatment and prognosis, he says.

When you tell people your diagnosis, they will likely ask what they can do to help. Kantrowitz recommends making a list of things you need to get done on a daily basis, including taking care of children, doing household chores, taking notes during doctor visits or sitting with you during treatments. When friends ask what they can do, find something on the list.

Once you tell people your diagnosis, they may want to keep up with your health. A point person can field phone calls and provide web-based updates on blogs, FaceBook accounts or websites like Caring Bridge or 

“Having someone taking calls for you, blogging or using the Internet so you don’t have to constantly answer calls is very, very helpful,” Baumgarten says.

Telling your employer about your diagnosis may require a different approach. It is important to let your employer know about your diagnosis in order to be covered under certain laws, including the Americans with Disabilities Act and the Family Medical Leave Act. Telling your human resources department is essential in providing time off, flex time and other workplace adaptations. Having a proactive plan, including any questions your employer would have, proposed leave time and discussion of a shift in duties may help the conversation go smoother. (For more information on talking to your boss about your cancer diagnosis, read “

Talking about your cancer with acquaintances or even strangers is not necessary, Baumgarten says.

“Have a couple of pat answers if you run into someone at the grocery store and they ask about you,” she advises. Phrases such as “It’s going on schedule” or “It’s going fine” can help you get out of the conversation quickly without insulting anyone when you are caught off guard, Baumgarten says.

Disclosing your cancer is the result of a myriad of personal parameters, and there is no one correct way. Women may tend to tell more than men. Cancers that are easier to beat may be easier to disclose than cancers with a high mortality rate. Cultural differences can also be an important factor. (Read “

But the bottom line, says Baumgarten: Tell someone in your life to make coping with cancer more manageable.

Having a plan makes it easier when telling loved ones about a cancer diagnosis. 


Diagnosis Disclosure

To combat medical indebtedness, some survivors of cancer and other catastrophic illnesses are ending up in bankruptcy court. A 2005 study published in the journal Health Affairs estimated that medical bankruptcies affect about 2 million Americans every year, including not just debtors, but their dependents.

Bankruptcy laws enable people who can no longer pay their creditors to begin their financial lives again, usually by creating a manageable repayment plan. 

Cancer survivors in bankruptcy court have the highest annual out-of-pocket medical expenses of all medical cases, averaging $35,000 per patient, according to figures from The University of Texas M.D. Anderson Cancer Center.

Despite changes in bankruptcy law in 2005, medical debt still can be discharged, whether it’s on credit cards or with care providers, says Mark Scarberry, Pepperdine University law professor and fall 2007 resident scholar at the American Bankruptcy Institute. “The usual result is it will be discharged, so the patient won’t be responsible for it anymore, and the doctors and hospital will likely get nothing. But the change in the law has frightened some people away from filing.”

Misinformation about changes in the law is abundant, but Scarberry says that the bankruptcy system is still a very viable option for people with unmanageable debt.

“Look at your debt, and if there is no way to pay it back and maintain a reasonable standard of living, and you see no future way out of it, then it’s probably time,” he says.

To combat medical indebtedness, some cancer survivors are ending up in bankruptcy court. 

Bearing the Bankruptcy Burden

Healthcare advocates say one crucial thing to do before entering the hospital is to check whether labs, doctors and tests are “in network” for your plan. Just because the hospital is part of your insurance network does not mean that the other services you receive are. Use hospital social workers as a resource early in the process if you suspect financial problems will arise. 

Also, it’s important to shop around for care if you have time before your procedure and ask for an estimate upfront. Look for state or county-run hospitals, or not-for-profit providers, which tend to offer more free care and provide payment plans for patients. Also look for free clinical trials through the National Cancer Institute’s website at 

If your treatment causes unmanageable medical bills, there are also a number of strategies you can use:

First, be sure hospital charges are accurate.

 Errors in medical accounts can often be caught if you call them to the attention of the hospital’s billing department. Also, check that your insurance is covering everything it’s supposed to cover, and don’t be afraid to file an appeal if necessary. Request one case manager at your insurance company to handle your needs.

 You may qualify for government programs such as Medicaid, the state Children’s Health Insurance Program or Social Security Disability. In some cases, coverage can be retroactive. Also, grants of private assistance to cover medical bills may be available through a local hospital or charity group or national organizations. (See 

Talk to providers directly and ask for discounts and extended payment plans.

 They often will not offer unless you ask. For ongoing costs, see whether your doctor can write prescriptions for extended periods to cut down co-payments, and ask about other cost-saving strategies. Many doctors will work something out as long as you pay consistently. Also, see whether the clinic has drug samples or other discount coupons.  

It’s important to shop around for care if you have time before your procedure and ask for an estimate upfront.

 Advocates say these cards are increasingly being pushed on patients upfront as healthcare providers partner with credit card companies. While the cards have an appealing start-up with no fees and zero interest rate, the cards often go to much high interest rates and fees after the grace period. Putting the medical expenses on a card also eliminates your ability to negotiate with your provider for discounts or extended payment plans.

If you own your home, call your mortgage lender early and try to work out new payment arrangements.

 Some people might consider downsizing their home or taking a second mortgage, reverse mortgage or home equity loan to cover medical expenses. However, experts warn this should be a last resort and done cautiously, because you are trading secured for unsecured debt.

 Don’t forget, you can deduct the part of medical and dental expenses that are more than 7.5 percent of your adjusted gross income from your federal taxes. For a list of acceptable medical and dental expenses, go to the IRS website at www.irs.gov and search for Publication 502.

 Creative fundraising efforts are often successful. Go to local media for publicity. In addition, filing for personal bankruptcy can discharge expenses owed a provider, as well as credit card debt.  

Advice from advocates on how to avoid debt and get help with bills.

Teresa McUsic

Pass the Salt

Diagnosis Disclosure

Bearing the Bankruptcy Burden

Debt-Fighting Strategies

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