With better control of chemotherapy side effects, cancer treatment is going more smoothly for many patients.
The goal of chemotherapy is to destroy cancer cells. Traditional chemotherapies work by killing cells that divide rapidly. As they wipe out fast-growing cancer cells, though, they can also damage fast-growing healthy cells.
Damage to blood cells, for example, leads to side effects such as anemia, fatigue, and infections. Chemotherapy can also damage the cells that line the mucous membranes found throughout the body, including those inside the mouth, throat, and stomach. This leads to mouth sores, diarrhea, or other problems with the digestive system. And damage to cells at hair roots, or hair follicles, leads to hair loss.
Each person with cancer reacts differently to chemotherapy and its various side effects. Fortunately, doctors now have many ways to reduce and even prevent these side effects. In this e-booklet, you’ll find practical information on managing side effects so that your treatment goes as smoothly as possible.
You should note that there are newer medications, known as targeted treatments, are not discussed in this e-booklet. These medications were developed, in part, to cause less severe side effects than traditional chemotherapy. Many people taking these drugs develop a skin rash and other bothersome skin and nail conditions. Patients most likely to be affected are those taking a particular type of targeted treatment called an EGFR inhibitor. You can learn more about how to cope with skin rash from targeted treatments in the CancerCare Connect booklet Tips for Managing Treatment-Related Rash and Dry Skin.
Possible Side Effects of Chemotherapy
Your body’s reaction to chemotherapy depends on a number of things such as length of treatment, dosage prescribed, and your personal health history. Most side effects are short term, but some can last throughout your treatment and even for some time afterward. Although side effects can be uncomfortable or even painful, there are many ways your health care team can provide you with relief. This section describes various side effects that may result from chemotherapy. Treatment options and coping tips are also discussed.
Nausea and Vomiting
Many surveys have shown that patients and their family members believe that nausea and vomiting occur with all types of chemotherapy. More than 20 years ago that was true, and it was difficult to control the symptoms. Today, doctors do a much better job of preventing and easing these symptoms.
Generally, if there’s more than a 10 percent risk of causing nausea or vomiting with chemotherapy, patients are given anti-nausea medicines — also known as anti-emetics — to prevent the symptoms. When it comes to nausea and vomiting, we know that younger people are more at risk than older people, and that women are at a slightly greater risk than men.
Certain drugs commonly cause nausea and vomiting, including:
- Cisplatin (Platinol and others)
- Cyclophosphamide (Cytoxan)
Doctors have used these standard chemotherapies for many years.
Treating Nausea and Vomiting
There are many options available to help you manage nausea and vomiting. Talk with your doctor about which one is best for you. In general, anti-nausea medicines are given to prevent the problem from occurring in the first place.
The most common form of anti-nausea medication is a combination of dexamethasone (a type of steroid) and a serotonin blocker. These blockers stop the natural substance serotonin from sending a message to the brain that triggers nausea. Serotonin blockers include dolasetron (Anzemet), granisetron (Kytril and others), ondansetron (Zofran and others), and palonosetron (Aloxi).
This combination helps prevent symptoms that occur in the first 24 hours after chemotherapy, known as acute nausea. Doctors usually recommend patients continue using this drug combination for two to three days following treatment to prevent delayed nausea. By taking medication to prevent these different types of nausea, patients can also avoid developing anticipatory nausea — the queasy feeling that can come before treatment. Sometimes, just the smells, sights, and sounds of the treatment room can trigger nausea and vomiting before a new cycle of chemotherapy has even begun.
Aprepitant (Emend) is an anti-emetic drug that can be added to the combination of dexamethasone and a serotonin blocker. Together, these drugs protect against both acute and delayed nausea and vomiting. Aprepitant, taken as a pill, works by blocking the effects of a chemical produced in the body called “substance P.” A related drug, fosaprepitant (Emend for Injection), may also prevent nausea and vomiting brought on by chemotherapy. Delivered intravenously, fosaprepitant is converted to aprepitant in the body.
Coping with Nausea and Vomiting
In addition to medical treatments for nausea and vomiting, there are things you can do to ease symptoms. For example:
- Eat and drink slowly. Try having small meals throughout the day instead of your usual breakfast, lunch, and dinner.
- Avoid sweet, fried, or fatty foods, as well as foods with strong odors. Eating foods cold or at room temperature can help you avoid strong smells.
- Be sure that you fully understand your doctor’s and nurse’s instructions for taking anti-nausea medicines.
- See that you have a good supply of the correct drugs.
- Be sure that you are drinking enough fluids. Ask your nurse or doctor about proper nutrition, which is especially important during this time.
- Find out from your doctor if any other medicines you may be taking require special precautions.
Feeling tired — really tired — can be tied to a number of factors:
- The cancer itself
- Treatment of the disease
- The emotional aspects of coping with cancer and cancer pain
- Anemia (low levels of red blood cells)
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.
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 (anemic). 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 over-the-counter medicines for “iron-poor blood.” These medicines have not proven to be helpful.
Coping with Fatigue
These tips can help you reduce your fatigue:
- Take several short naps or breaks in a comfortable chair rather than in bed.
- Take short walks or do some light exercise, if possible.
- Try easier or shorter versions of the activities you enjoy.
- Ask your family or friends to help you with tasks you find difficult or tiring.
- Save your energy for things you find most important.
- Talk to an oncology social worker or oncology nurse. These professionals can also help you manage fatigue. They can work with you to deal with any emotional or practical concerns that may be causing symptoms and help you develop ways to cope.
Mouth Sores (Mucositis)
Radiation treatments and some types of chemotherapy can cause sores inside the mouth and on the mucous lining of the throat and digestive tract. Mucositis can be a serious problem because it can cause pain and infections, making it difficult to eat, drink, and swallow.
Once treatment ends, mouth sores do disappear. But before they fade, 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 to manage mucositis is to take good care of your mouth and keep it clean. Here are some tips:
- Visit your dentist before treatment. A small problem could turn into a large one if mouth sores develop later on.
- Choose a soft bristle brush for brushing your teeth.
- If toothpaste irritates your mouth, use a mixture of ½ teaspoon salt with 4 cups water.
- Gargling may also help. Use a solution made up of 1 quart plain water, ½ teaspoon table salt, and ½ teaspoon baking soda.
- Drink plenty of fluids.
Soothing Mouth Pain
Some options for soothing mouth pain include:
- Ice chips or Popsicles.
- Ibuprofen (such as Motrin) or acetaminophen (such as Tylenol) for mild pain.
- Over-the-counter anesthetics, such as Anbesol, Xylocaine, or Orajel. Let your doctor know if you are using them, especially if he or she prescribes a lidocaine-based mouthwash.
- Gelclair — an oral gel designed to coat and soothe mouth sores by forming a protective barrier in the mouth. This product is available by prescription only.
- “Magic mouthwash” is another prescription product designed to soothe mouth sores. It contains Maalox to coat the mouth and lidocaine to relieve the pain. Some pharmaceies that specialize in cancer care offer their own version of magic mouthwash.
- Opiates, a class of drugs that includes morphine, may also be prescribed to help you cope with mouth pain. A fast-acting opiate called fentanyl citrate (Actiq) is available in a berry-flavored lozenge on a stick. It may be used to help prevent mouth sores. Like a cough drop, the lozenge dissolves in the mouth, and the drug is delivered quickly into the bloodstream.
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 can include:
- Difficulty picking up objects or buttoning clothing
- Problems with balance
- Difficulty walking
- Jaw pain
- 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. In the meantime, take extra caution when handling hot, sharp, or dangerous objects. And use handrails on stairs and in the tub or shower.
As we mentioned earlier, chemotherapy can lower the levels of infection- fighting white blood cells, a condition known as neutropenia. Of special concern of people with cancer is their level of neutrophils, the most abundant of the different types of white blood cells. These cells contain tiny packets filled with potent chemicals called enzymes that can destroy bacteria when the chemicals are released.
Bacteria are the most common source of infection for patients receiving chemotherapy. The normal number of white blood cells in one microliter of blood (a tiny droplet, one millionth of a liter) is between 4,000 and 11,000; the risk of infection is increased when the neutrophil count drops to 1,000 or fewer. If your neutrophil count dips below this number, you might experience chills, fever, or sweats.
If you are feeling unwell in any way after receiving chemotherapy, it’s important to take your temperature. Temperatures from 99°F (37.2°C) to 100°F (37.8°C) are fairly common. But if your temperature rises to 100.5°F (38.1°C) or above, call your doctor or nurse immediately. Fever may be your only sign of an infection. Unless fever is treated promptly, infections can become life- threatening. Make sure you have a good thermometer that is easy to use and read (the digital ones are fine). Also, be sure to have your doctor’s telephone number in case there is a problem.
Doctors use antibiotics to treat infections. Although most people think of antibiotics as pills, intravenous antibiotics are often recommended for people on chemotherapy. Using intravenous antibiotics knocks out infections until the white blood cell count returns to normal.
Depending on a number of things, including the type of chemotherapy you receive, another approach is to take medicines known as white blood cell growth factors. Growth factors stimulate the bone marrow to replace blood cells affected by chemotherapy. In some patients, these drugs can reduce the risk of getting infections.
Commonly used white blood cell growth factors include filgrastim (Neupogen) and pegfilgrastim (Neulasta). Both of these drugs have to be given by injection. Your doctor or nurse can train you or a caregiver to administer this injection at home if you prefer.
You can lower your risk of infection by taking these simple steps:
- Wash your hands often with soap and water, especially after using the toilet and before eating.
- Clean cuts and scrapes right away. Use an antiseptic and keep wounds clean and dry until they heal.
- Carry alcohol-based sanitizers, such as Purell, with you in case you don’t have access to soap and water.
- Be extra careful not to nick or cut yourself when using a razor, knife, or scissors.
- Wear protective gloves when gardening or cleaning up.
- Avoid contact with cat litter boxes, bird cages, and fish tanks.
Defined as two or more loose stools per day, diarrhea may be caused by some types of chemotherapy, including:
- Irinotecan (Camptosar and others)
- 5-fluorouracil (5-FU)
- Erlotinib (Tarceva)
- Gefitinib (Iressa)
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.
Replacing Lost Fluids and Salts
If you are experiencing diarrhea, it is very important to drink plenty of fluids such as water.
You can also increase your intake of drinks such as Gatorade or Pedialyte, an over-the-counter solution made for infants that can be used by adults as well. These drinks provide electrolytes — the body’s salts that must stay in balance in order for cells to work properly. Occasionally, intravenous fluids are needed if the diarrhea is especially severe.
Making Changes to Your Diet
Many foods can nourish you without contributing to diarrhea. Here are some suggestions for making healthy choices:
|High-protein foods such as eggs (well cooked), lean meat, fish, or 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.
Taking Medicine for Diarrhea
Over-the-counter medicines and prescription treatments are available for diarrhea, but you should only use them if they are necessary.
The most recommended over-the-counter medicine for diarrhea is Imodium AD. But you should remember that this used to be a prescription medicine and can be quite powerful. In general, if the diarrhea is bad enough for you to need a medicine, including an over-the-counter one, you should discuss the diarrhea and treatment with your doctor or nurse.
Your doctor may need to prescribe something stronger, such as diphenoxylate and atropine (Lomotil and others). Like all drugs, these products can interact with other drugs you may be taking, such as opiate pain relievers.
For severe diarrhea that does not respond to these oral medications, your doctor may consider giving you injections of octreotide (Sandostatin and others). Although this drug has not been approved specifically for diarrhea caused by chemotherapy or radiation treatments, your doctor may choose to prescribe it “off label.”
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 (Oncovin and others), and temozolomide (Temodar)
- 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 patients mistake for diarrhea. They may take an antidiarrheal medication, making the problem worse. With prolonged constipation, other symptoms, such as confusion and retaining urine, can occur.
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 light exercise a part of your everyday schedule.
Stool softeners such as docusate sodium (Colace and others), although helpful, are not enough to manage this side effect. Pharmacies carry a number of different laxatives that are available without a prescription such as senna (Senokot and others), bisacodyl (Correctol, Dulcolax, and others), magnesium hydroxide (milk of magnesia), Metamucil and MiraLAX.
The best thing to do is to prevent constipation through diet, exercise, and careful use of laxatives. Prescription pain medicines may be one of the biggest reasons people with cancer experience constipation. But your doctor can prescribe a special schedule of laxatives along with your pain medication so that you can still benefit from pain relief and avoid constipation.
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 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 starts to grow back when you are finished with treatment. It may have a different texture or color, but these changes are usually not permanent.
Coping With Hair Loss
Generally, when they lose their hair, most people want 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 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 of these salons even specialize in hair loss from chemotherapy.
Your Support Team
When you or a loved one is diagnosed with cancer, it’s common for many emotions and issues to arise. Sometimes it helps to talk to someone. Just getting your concerns out into the open can help make them seem more manageable.
It’s perfectly normal to feel sad, angry, afraid, or frustrated about the side effects of chemotherapy. If you are experiencing fatigue or nausea, for example, you may not be able to do all the things you’re used to doing. Your family may feel the effects, too. Perhaps you have a young child at home who doesn’t understand why you don’t have energy to play. Or maybe you need some accommodations made for you at work, such as a place where you can go to rest or more flexible hours.
Social workers and oncology nurses can help. These health care professionals provide emotional support, help you cope with your treatment and its side effects, and guide you to resources and practical solutions for problems. CancerCare offers free individual counseling online, over the phone, and in person with oncology social workers on staff.
You and your family members may also benefit from a support group, which can ease the feeling that you are going through treatment side effects alone. By providing reassurance and sharing insight and suggestions, people in support groups often help each other learn new ways to cope. CancerCare offers free telephone and online support groups for people living with cancer, caregivers, and loved ones. These groups are led by professional oncology social workers.
To learn more about how CancerCare helps, call us at 800-813-HOPE (4673) or visit www.cancercare.org
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 responsive your tumor has been to chemotherapy, the current goals of treatment, and whether there are effective drugs 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 is cumulative, the symptoms may get worse before they get better. Talk with your doctor or nurse about medications, as well as techniques such as relaxation exercises and acupuncture, which 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 is the most common organism that causes infections, and what antibiotics are used?
A. There are many different organisms that can cause infection. That is why a broad-spectrum antibiotic (an antibiotic used to treat a wide range of bacteria) 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. Patients often notice these changes during chemotherapy treatment. But most people 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, since some medications can also make you less alert.
Charles L. Loprinzi, MD
Regis Professor of Breast Cancer Research
Mayo Clinic College of Medicine
Carolyn Messner, DSW
Director of Education & Training