With better control of side effects from chemotherapy, treatment is going more smoothly for many people with cancer.

The goal of chemotherapy is to destroy cancer cells.
Traditional chemotherapies work by killing cells that divide rapidly. But as they wipe out fast-growing cancer cells, they also can damage fast-growing healthy cells.

Damage to healthy blood cells, for example, can lead to side effects such as fatigue or infection. Chemotherapy can also damage the cells that line mucous membranes throughout the body, including those inside the mouth, throat and stomach. This can lead to mouth sores, diarrhea or other issues with the digestive system. And damage to cells at the hair roots, or follicles, can lead to hair loss.

Each person with cancer reacts differently to chemotherapy and its potential side effects. Fortunately, doctors now have ways to reduce and even prevent these side effects. In this booklet, you’ll find practical information on managing side effects from chemotherapy so that your treatment goes as smoothly as possible.

To help you get relief, your doctors and nurses need to know specific details about your symptoms. By keeping a side effects journal and bringing it with you to medical appointments, you can have this kind of information ready to share with your health care team. Some of the things you may want to write down in your journal include:

• The date and time a side effect occurs
• How long it lasts
• How strong it is—for example, if you experience pain, how strong is it on a scale from 1 to 10, with 1 being the least amount of pain and 10 the most intense?
• How your daily activities are affected—did any side effect of your medication keep you from sleeping, eating, walking, working or exercising?
• Any other questions or concerns that come up between appointments with your health care team

Good communication with your doctors and nurses is especially important if you decide to take part in a clinical trial. Clinical trials are studies that test new treatments to see how safe and effective they are for patients.

Your doctor, who knows the most about your specific type and stage of cancer, can guide you in making a decision about whether a clinical trial is right for you.

Chemotherapy-Induced Nausea and Vomiting (CINV)

When chemotherapy enters the body, sensors in the digestive system and brain detect its presence as a foreign substance. In a complex series of signals among the brain and the mouth, stomach, small intestine and bloodstream, the medication stimulates the “vomiting center” in the brain. Several chemicals, including ones called serotonin and substance P, are released, triggering the nausea and vomiting reflex. This is the body’s effort to get rid of the foreign substance.

Some people experience CINV within the first few hours of receiving chemotherapy. Doctors call this reaction “acute nausea and vomiting.” Other patients don’t feel symptoms the day of chemotherapy but may develop nausea and vomiting during the next few days. This condition is called “delayed nausea and vomiting.”

You shouldn’t assume that nausea and vomiting that occurs a day or two after treatment isn’t related to chemotherapy. It’s important to tell your doctor or nurse when you experience these symptoms, no matter when they occur.

Because some people getting chemotherapy expect to feel ill, they start experiencing symptoms even before their treatment begins. This is referred to as “anticipatory nausea and vomiting.” Sometimes, the sights, sounds or smells of the treatment room can trigger this reaction.

Treating Nausea and Vomiting

Drug companies have been developing anti-nausea medications for the past 40 years. Your doctor will decide which drugs to prescribe based on the type of chemotherapy you are getting and how much nausea and vomiting might be expected. Sometimes, patients receive anti-nausea drugs intravenously through a needle inserted into a vein. Other antinausea medications are available in pill or liquid form to take by mouth, as a skin patch or as a suppository (a soft cone- or cylinder-shaped capsule containing medication that dissolves in the rectum).

After chemotherapy, you may also be given anti-nausea medications to take at home. It’s important to understand how these drugs should be taken. To prevent CINV, some medications are designed to be taken for several days, whether you feel nauseous or not. Others are meant to be taken only when you feel nauseous. If you have questions about when you should take your anti-nausea medication, be sure to call your doctor or nurse.

It is vital that you have a clear understanding of the order in which you take your medications—both chemotherapy (whether intravenously or by mouth) and anti-nausea drugs— as well as the times at which you take them.

If you are taking the medications as directed and you continue to have CINV, contact your doctor right away. It’s very important to stay hydrated (keep fluids in your system) so that the body’s salts, or electrolytes, stay in balance and the cells can work properly. See “Coping With Nausea and Vomiting” on the right side of this page for tips on staying hydrated.

Generally, anti-nausea drugs fall into the following categories:

Corticosteroids. Related to the natural hormone cortisol, corticosteroids are widely used to help prevent CINV. They have been used successfully for many years, especially to prevent delayed nausea and vomiting. Corticosteroids such as dexamethasone may be given in many different forms and are often combined with other anti-nausea medications for the most benefit.

Serotonin antagonists. This type of medication blocks natural substances from sending a signal to the brain that causes vomiting. Palonosetron (Aloxi) continues to work for days after a single injection. It can prevent both acute and delayed nausea and vomiting. Other serotonin antagonists available in the United States include ondansetron (Zofran and others), granisetron and dolasetron (Anzemet), which can all be given as a pill or injection. Ondansetron and granisetron are both available in liquid form, and ondansetron also comes in a tablet that dissolves in the mouth. These forms of medication are especially helpful for people who have trouble swallowing pills or keeping them down when they are feeling nauseous.

Dopamine antagonists. Metoclopramide (Reglan and others) and prochlorperazine are two commonly used medicines in this class of drugs. They are often prescribed for “breakthrough” nausea and vomiting—that is, symptoms not already controlled with other types of medications.

NK-1 inhibitors. This is the newest class of medicines to prevent CINV. Aprepitant (Emend and others) is used when patients receive chemotherapy that is very likely to cause acute or delayed nausea and vomiting. Available as a capsule, aprepitant is taken before a chemotherapy session and for two days afterward. A related drug, fosaprepitant dimeglumine (Emend for Injection), is delivered intravenously and converted to aprepitant in the body.

Cannabinoids. These medications contain a purified form of the active ingredient found in marijuana. For a number of years, doctors have prescribed dronabinol (Marinol and others) tablets as an anti-vomiting drug. In 2006, the U.S. Food and Drug Administration approved nabilone (Cesamet) tablets, which can control CINV in cancer patients who have not been adequately helped by other anti-nausea medications. Like marijuana, dronabinol and nabilone can cause sedation (relaxation or sleepiness) and mood changes.

Motion sickness treatments. Like cannabinoids, these types of medication are helpful in reducing any nausea or vomiting that lingers more than a few days after chemotherapy. Scopolamine (Transderm Scop) comes as a patch to be placed on the skin behind the ear. Although scopolamine was not originally intended for people on chemotherapy, it can be used to treat CINV.

Anti-anxiety drugs. Medications such as lorazepam (Ativan and others) are used to sedate patients and to help block nausea and vomiting. Sedatives can be given intravenously and in pill form. To avoid becoming dependent on such medications, a careful schedule should be worked out with your doctor or nurse.

Stomach acid blockers. Known as proton pump inhibitors and histamine H2-receptor antagonists, these medications block the formation of stomach acid. This reduces indigestion and heartburn, which can sometimes lead to nausea and vomiting. All of these drugs can be bought without a prescription, and they are often available in less-expensive, generic forms. Be sure to talk with your doctor first before using over-thecounter drugs. Examples of these drugs include omeprazole (Prilosec and others), lansoprazole (Prevacid and others), pantoprazole (Protonix and others), cimetidine (Tagamet and others), famotidine (Pepcid and others) and ranitidine (Zantac and others).

Fatigue

Feeling tired—really tired—may be tied to a number of factors:

• Cancer treatment
• The cancer itself
• The emotional aspects of coping with cancer and cancer pain
• Anemia (low levels of red blood cells, the iron-containing cells that carry vital oxygen from the lungs to the muscles and other tissues in the body)

If you are experiencing fatigue, you should know that this is a symptom for which you can and should seek help. If your doctor doesn’t ask you about fatigue, be sure to bring it up. That’s the best way to find and treat the cause.

Treating Fatigue

To determine whether there is an underlying physical cause, your doctor may order a blood test to find out if your red blood cell count is abnormally low. If you are anemic, there are treatment options available. Be sure to take only treatments prescribed by your doctor. Don’t try to treat yourself with overthe- counter medicines for “iron-poor blood.” These medicines have not proven to be helpful.

Mouth Sores (Mucositis)

Radiation treatments for head and neck cancer and some types of chemotherapy can cause sores inside the mouth and on the mucous lining of the throat and digestive tract. These sores, called mucositis, can be a serious problem because they can cause pain and infections, making it difficult to eat, drink and swallow.

Once treatment ends, mouth sores do disappear within a few weeks. But before they start and while they are present, it’s important that you work closely with your health care team to manage this side effect of cancer treatment.

Maintaining Oral Health

One of the key things you can do to manage mucositis is to take good care of your mouth, including keeping it clean. Here are some tips:

• Visit your dentist before treatment. He or she can make sure that your mouth is as healthy as possible before you begin treatment and can provide important information to the rest of your health care team.

• Choose a soft-bristle brush for brushing your teeth.

• If toothpaste irritates your mouth, use a mixture of a half teaspoon of salt with four cups of water.

• Gargling may also help. Use a solution made up of one quart of plain water, a half teaspoon of table salt and a half teaspoon of baking soda.

• Drink plenty of fluids.

Nerve Damage

Some people on chemotherapy experience numbness or tingling in their hands and feet—what doctors call peripheral neuropathy. Symptoms related to neuropathy and other types of nerve damage may include:

• Difficulty picking up objects or buttoning clothing
• Problems with balance
• Difficulty walking
• Hearing loss

These symptoms can build over time. Some people don’t notice them until they have had several chemotherapy treatments.

Managing Nerve Damage

It’s important to tell your doctor as soon as possible if you experience these types of side effects. He or she may want to adjust some of your medicines or chemotherapy and may want to see if there is another reason for the problem that can be treated.

Often, nerve damage is temporary; it will usually get better, but it can take time. If you have neuropathy, take extra caution when handling hot, sharp or dangerous objects. And use handrails on stairs and in the tub or shower.

Neutropenia and Infections

The term “neutropenia” refers to an unusually low number of neutrophils, a type of infection-fighting white blood cell. Because neutrophils are short-lived, the body produces about 100 billion of these cells every day. They play a key role in maintaining good health by seeking out and destroying harmful bacteria.

Chemotherapy can reduce the number of neutrophils in the blood, which can lead to fever (febrile neutropenia), as well as infections—some of which can be serious and life-threatening. Doctors rate the severity of neutropenia based on the number of neutrophils per microliter of blood (one-millionth of a liter, or quart). A blood test measures the neutrophil count: 1,700 per microliter or above is considered normal; 1,000 to 1,500 is mild neutropenia; 500 to 1,000 is moderate; less than 500 is severe. The risk of infections rises when neutropenia is more severe and long-lasting.

Neutrophil counts usually start to drop about a week after each round of chemotherapy begins. They often reach a low point (called the nadir) about seven to 14 days after treatment. This is when infections are more likely to develop. The neutrophil count starts to rise again as the bone marrow resumes its normal production of neutrophils. It can take as long as three to four weeks to reach a normal level again.

If neutropenia develops or the neutrophil level does not return to normal quickly enough, a doctor may delay the next round of chemotherapy or recommend a lower dose.

People who receive standard chemotherapy treatments for most solid tumors such as breast or lung cancer have a lower risk of developing neutropenia than do those with leukemia or lymphomas. But it’s important for all people with cancer to be aware of this side effect and to work closely with their health care team to prevent and treat it effectively. After a chemotherapy session, call your doctor or nurse if you notice any of these symptoms:

• Fever (body temperature above 101ºF)
• Sore mouth or gums
• Pain or swelling in the gums
• Swollen, inflamed or pus-filled skin sores
• Sinus or ear infections
• Cough and shortness of breath with fever
• Irritation in and around the anus

Treating Infections

Doctors use three main types of medications to treat the effects of neutropenia: antibiotics for bacterial infections; antifungal drugs for fungal infections found in the throat or lungs, for example; and granulocyte colony-stimulating factors (G-CSFs) to raise the number of white blood cells. For some people, continual use of antibiotics or antifungals as a preventive measure may be beneficial.

G-CSFs are used both to treat neutropenia and prevent it if a person is at increased risk of developing the condition after receiving chemotherapy. They work by stimulating the bone marrow to produce more white blood cells. Both filgrastim (Neupogen) and tbo-filgrastim (Granix) are given by injection once daily for several days, until the neutrophil count returns to normal. A long-acting G-CSF, pegfilgrastim (Neulasta), also is available. Because it stays in the body longer, only a single injection of pegfilgrastim is needed per round of chemotherapy.

Diarrhea

Defined as two or more loose stools per day, diarrhea may be caused by certain chemotherapy drugs, including irinotecan (Camptosar and others), fluorouracil (5-FU) and capecitabine (Xeloda and others).

There are many things you can do to help control diarrhea. If diarrhea persists, especially large and frequent stools, you should report it to your doctor or nurse.

Making Changes to Your Diet

Many foods can nourish you without contributing to diarrhea.
Here are some suggestions for making healthy choices:

CHOOSE

INSTEAD OF

High-protein foods such as eggs (well cooked), lean meat, fish, poultry, smooth peanut butter* or beans* Fried or fatty foods (such as sausage, bacon, chicken nuggets, fried seafood or pizza)
Skim or low-fat milk, yogurt or cottage cheese (use lactose-free dairy products if you are lactose intolerant) Regular milk or cheese with more than 9 grams of fat per ounce
Cooked vegetables* such as carrots, green beans or mushrooms Raw vegetables, especially those with thick skins, seeds or stringy fibers
Fresh fruits without the skin or canned fruit (except prunes) Dried fruits
Desserts low in fat and lactose, such as sorbets, fruit ices or graham crackers High-fat ice creams or any candies, gum, or breath mints containing sorbitol, mannitol or xylitol

Note: Foods marked with an asterisk (*) are high in soluble fiber, which forms stools but also can increase the amount of stool. Choose them when you can manage more stools.

Constipation

Defined as fewer than three bowel movements a week (although fewer than four or five may be a reduced number for some people), this symptom can be caused by:

• Certain chemotherapy drugs, including vinorelbine (Navelbine and others), vincristine and temozolomide (Temodar and others)
• Inactivity
• Low fluid intake
• Low amounts of fiber in the diet
• Anti-nausea medications
• Opiate pain medications

In cases of severe constipation, liquid can seep around a blockage, which some people mistake for diarrhea. They may take an anti-diarrheal medication, making the problem worse. With prolonged constipation, other symptoms, such as confusion and retaining urine, can occur.

Avoiding Constipation

Here are some things you can do to help prevent constipation:

• Eat plenty of dietary fiber. Grains, beans and vegetables such as cauliflower or broccoli are good sources of fiber.
• Drink plenty of fluids.
• Make exercise a part of your everyday schedule.

Hair Loss

Not all anti-cancer medicines cause hair loss; your doctor or nurse can tell you whether you might be affected. Hair loss is often one of the more frustrating aspects of cancer treatment. When hair falls out, it can affect a person’s self-image and quality of life. But there are ways to cope with this side effect.

Everyone’s experience is different, so it’s important to talk with your doctor or nurse about how your particular treatment affects hair loss. Depending on the treatment, hair loss may start anywhere from seven to 21 days after the first chemotherapy session. Hair usually starts to grow back after you are finished with treatment. It may have a different texture or color, but these changes may not be permanent.

Coping With Hair Loss

Many people who lose their hair after cancer treatment choose to wear some kind of head covering, whether it’s a scarf, turban, hat or wig. Some insurance plans cover part of the cost of these head coverings. Organizations such as CancerCare® can also suggest places where you can find wigs.

If you choose to wear a wig, consider buying one before all of your hair falls out. This way, you will have a good match to your own hair color. Having a wig ahead of time will also help you feel more prepared. You can have your wig professionally fitted and styled by a full-service wig salon. Some salons specialize in hair loss from chemotherapy.

Frequently Asked Questions

Q. I’ve had some nerve damage as a side effect of my treatment. Should my doctor consider changing the type of chemotherapy I’m getting?

A. This is a judgment call. You and your doctor have to weigh the risks and benefits of your treatment. The decision will depend on how severe your symptoms are, where you are in the course of your treatment, how much your tumor has responded to chemotherapy, the current goals of treatment and whether there are other effective drugs available that do not cause nerve damage. However, even if you stop using a medicine today, you will probably continue to have symptoms for some time. And because nerve damage builds up over time, the symptoms may increase before they decrease. Talk with your doctor or nurse about medications, as well as other treatments that may help ease discomfort.

Q. I haven’t experienced many side effects from my chemotherapy, so I’m wondering whether my treatment is really working.

A. Sometimes, people can benefit from chemotherapy without having a lot of side effects or possibly even any side effects. An important goal is to prevent side effects, and it sounds as though you and your doctors have been able to do that. Not having side effects might be due to other factors as well. For example, every drug affects each person differently and at different stages of treatment. And some chemotherapy drugs are known to cause less severe side effects than others.

Q. When a patient has neutropenia (a low white blood cell count), what are the most common types of bacteria that cause infections, and what antibiotics are used?

A. There are many different bacteria that can cause infection. That is why a broad-spectrum antibiotic (an antibiotic used to treat a wide range of these organisms) is usually prescribed to treat infection. Doctors see different patterns of infection in different geographic regions. These patterns help doctors decide which medicines are given to treat infections and prevent them from becoming worse.

Q. There have been many discussions in my support group and on the Internet about the side effect referred to as “chemobrain.” What is chemobrain, and what can be done about it?

A. If you are having memory problems and trouble focusing on tasks, finding words or managing daily activities, you are not alone. Many people notice these changes while receiving chemotherapy. But most find that within a year of finishing treatment, these symptoms have either greatly improved or disappeared altogether. Researchers are still uncertain about the exact causes of chemobrain. But a number of conditions that may lead to these symptoms can be treated effectively: low blood cell counts, depression, anxiety and fatigue among them. Tell your doctor if you’re having any of the symptoms of chemobrain. Sometimes, simply changing a prescription can make a real difference in how you feel, because some medications can also make you less alert.

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This booklet was made possible by Teva Pharmaceuticals and an educational donation provided by Amgen.

Last updated July 31, 2014

The information presented in this publication is provided for your general information only. It is not intended as medical advice and should not be relied upon as a substitute for consultations with qualified health professionals who are aware of your specific situation. We encourage you to take information and questions back to your individual health care provider as a way of creating a dialogue and partnership about your cancer and your treatment.