By Dr Eddy Bajrovic*
Cancer is many diseases. Even people with the same type of cancer can experience a very different journey through illness and treatment.
So, when it comes to overseas travel, deciding on what is feasible (and what’s not) requires some very personal considerations.
Most people with cancer travel without problems and a holiday relaxing or visiting family and friends overseas is often just the tonic they need.
But, some shouldn't travel by air while undergoing treatment because of dangers associated with deep vein thrombosis or changes in the pressure or oxygen concentrations in the plane's cabin. More later on some of the factors that could make international air travel not advisable.
Planning for healthy overseas travel is smart for anyone – sick or well – but particularly for someone with cancer or recovering from it.
And, preparations should start early, allowing enough time to cover the steps suggested in this checklist.
GET EXPERT ADVICE: The first step – before you book airfares or accommodation – is to talk to your oncologist and a doctor experienced in travel medicine to check that you are fit to fly. Depending on your condition, you may be advised to (a) stay in this region of the world rather than undertake a long-haul flight, (b) choose a developed country rather than a developing one, or instead (c) forego overseas travel and choose a domestic destination where medical help is more readily available and covered by Medicare.
PLAN WELL AHEAD: Allow plenty of time – at least 6-8 weeks, longer if possible – in case you need to overcome any complications or to make special arrangements to protect your health, such as vaccinations and medical documentation (see more below).
PICK THE RIGHT PLACE: Places you’ve visited before may not be suitable now. A better choice may be somewhere that has facilities you may need close to your accommodation – especially if you tire easily and can’t walk long distances. (Some travel companies and resorts have medical officers who can provide practical advice, as well as arrange early boarding, wheelchairs, special diets, oxygen etc. Be clear about what they can supply and the cost, and what you will need to arrange separately. Prices can vary widely, so shop around.)
DISCUSS VACCINATIONS: Vaccinations are often recommended for international travel to prevent common infectious diseases that occur at a destination. What vaccines are recommended will depend on where you want to go, how well you are, and the demands of your current treatment regime.
Not all vaccines are made the same way and ‘live’ vaccines may not be recommended for someone if their cancer has weakened their immune system or they are taking certain cancer medications, are undertaking or have recently undertaken chemotherapy. Generally, cancer patients can receive inactivated vaccines, which contain a ‘killed’ virus or bacteria, although these may not be as effective as when your immune system is working normally. Inactivated vaccines that are safe for cancer patients include: Diphtheria, tetanus and polio (only available as a combined vaccine for adults), flu, hepatitis A and B, rabies, cholera, injectable typhoid, meningococcal meningitis, tick-borne encephalitis, and Japanese encephalitis (Jespect rather than Imojev). However, live vaccines contain a small amount of live virus or bacteria that has been altered to prevent infection. They’re fine if your immune system is strong, but they can be harmful for someone with a weakened immune system and therefore not recommended for a cancer patient while undergoing chemotherapy, or for at least 6 months afterwards depending on the type of treatment they received. (Autologous stem cell/bone marrow transplants can mean no live vaccines for up to 2 years post treatment.) If you have a weakened immune system you should not have the following live vaccines: rubella (German measles), measles or MMR (Measles, mumps and rubella), chickenpox, BCG (Tuberculosis), yellow fever, oral typhoid, shingles (Zostavax), and Imojev, the live attenuated Japanese encephalitis vaccine. NOTE: Sometimes proof of vaccination is required to enter or return from certain destinations, notably Yellow fever for many African and South American countries. If your doctor determines that this live vaccine could compromise your condition or treatment, customs officials will usually accept a letter from your doctor exempting you from having the vaccine; however it is best to check this with that country’s embassy or consulate.)
MALARIA PREVENTION MEDICINE: If you are travelling to a malaria-infected country and there’s a risk of exposure to the disease, you may be advised to take malaria prevention drugs. Having cancer doesn’t preclude these medications and your travel doctor will determine which antimalarials are suitable for the destination, ensuring that they won’t interact with other drugs you may be taking. It’s also important to take measures to avoid mosquito bites, especially as mosquito-borne diseases like dengue fever, chikungunya, and Zika virus are also likely to pose a risk in tropical and sub-tropical regions.
AVOID BLOOD CLOTS: Some people with cancer have a higher risk of developing blood clots (deep vein thrombosis or DVT) because they have more of the proteins and cell fragments (platelets) that help the blood to clot. Other reasons why people with cancer may be at higher risk include: the type of cancer they have, certain cancer drugs or hormone therapies like tamoxifen can raise the risk, surgery within the last few months, they’re less mobile or active, they smoke, or are taking the contraceptive pill. Sitting for long periods increases the risk of developing a blood clot, regardless of whether you are travelling by plane, train, coach or car. Your doctor may suggest blood thinning drugs before and after some journeys. On plane trips, walk up and down the aisle every hour and/or exercise your lower legs with a few minutes of foot extensions. Compression socks or stockings are widely available but they must be correctly fitted to be effective. Read more on ways of preventing blood clots.
TRAVELLING WITH MEDICATION: Plan how much medication you need to take with you and get those prescriptions filled well before you go. You may need to check with the consulate of the destination country regarding restrictions on the medication you wish to take abroad. If you’re taking any controlled drugs, such as morphine-based painkillers, you may need to make special arrangements – apart from the letter from your doctor listing the drugs you require regularly. If in doubt, check with the consulate of the destination country regarding restrictions on the medication you wish to take abroad. Take a copy of your prescriptions with you in case your medicines are lost or stolen and need to be replaced. The Australian Government’s smartraveller website has more advice on taking medicines abroad and other information, including the reciprocal health care available to Australian travellers.
ARRANGING OXYGEN SUPPLIES: In-flight oxygen is available from most airlines, but charges vary widely. Oxygen should be requested well in advance and is typically available only in 2- or 4-litre flow. Most airlines will also require a letter of medical clearance from your doctor at least 48 hours before the flight. US carriers will require a prescription for oxygen. If you need oxygen during your stay, make arrangements for a supply from your resort or hotel. I would advise against international travel for anyone requiring oxygen therapy unless the trip is essential.
INSURANCE IS A MUST: Travel insurance is absolutely essential for someone with cancer. Hospital treatment and repatriation to Australia can be extremely expensive – six figure bills are not uncommon. To cover your fitness to travel, you will usually have to supply your insurer with a letter from your cancer specialist. It pays to shop around – and check the fine print. It can be particularly difficult to get insurance for some places, such as the USA, because of their high medical costs. Cancer Council Victoria has a handy handout, Travel Insurance for People with Cancer. Prepared by a legal firm, it outlines types of travel insurance, what you're covered for (or not), and what to do if you're refused travel insurance due to your illness. You can call the council’s Cancer Helpline on 13 11 20 and request a copy, and find more information on insurance from smartraveller website or cancerresearchuk.
Things that may prevent travel
You should always get advice before booking air travel if you’ve had:
RECENT SURGERY: You should not fly within 10 days of bowel, chest or brain surgery because you may have air trapped in your body, which can expand and cause an increase in internal pressure. The air should have been absorbed into your system after 10 days– less for keyhole (laparoscopic) surgery.
BONE MARROW OR STEM CELL TRANSPLANT: These procedures often leave the recipient at higher risk of an infection. Regular check-ups and blood transfusions are commonplace in the 6 months following the operation. Your doctor may advise against travel during this period anyway, or until your blood counts return to normal, which can take up to 12 months.
A LOW PLATELET COUNT: Platelets are the cells in blood that help it to clot. Cancer treatment can lower your platelet count. To fly safely, your platelet count should be above 40,000 per cubic ml of blood.
BREATHLESSNESS: Your cancer or your treatment can cause breathlessness. Lower air pressure during a flight means lower oxygen levels in the cabin, which can make breathing difficult. The solution may be a supply of oxygen during the flight (see above).
For a cancer patient or anyone with a chronic medical condition, seeking expert advice well before departure will help to ensure the trip is both healthy and stress free.
* Dr Bajrovic is the Medical Director of Travelvax Australia.
Routine, recommended and required travel immunisations – along with expert tailored advice and information – are available during a pre-travel medical consultation at Travelvax Australia’s clinics nationwide. For advice or to make an appointment, please call 1300 360 164 (toll-free from landlines) during business hours.