Again, because chemotherapy can injure healthy, usually rapidly dividing cells (such as blood cells, hair follicles, skin cells, gastrointestinal tract and reproductive cells in the ovary and testicle) while it attacks cancer cells, a wide array of side effects can develop in a patient. You may experience no side effects or just a few. The kind of side effects and how severe they are will depend on the type and dose of chemotherapy, how your body reacts, your age and general health. Some of the more common side effects are described below.
The fatigue is the most common side effect and can feel like chronic exhaustion or being “wiped out”. It can last days, weeks, or months. It can be cumulative and increase with time. However, it usually goes away gradually as your body responds and recovers from treatment
Things you can do to help cope with fatigue include planning time to rest throughout the day; taking several short naps or breaks, rather than one long one; taking short walks or doing light exercise (with your doctor’s approval); eat well and avoid alcohol; continue to do what you enjoy doing, but listen to your body (if you feel tired, rest). On occasion stimulants may be suggested by your physician.
Nausea and Vomiting
Nausea and vomiting are common side effects of several chemotherapeutic agents. Chemotherapeutic drugs irritate the lining of the stomach and the small intestines as well as certain parts of the brain that control nausea. Although every patient is different, certain drugs are much more likely to cause nausea/vomiting than others such as cisplatin, carboplatinum, cyclophosphamide, procarbazine, adriamycin and dacarbazine.
Many things can influence the likelihood and severity of nausea and vomiting such as prior experience with motion sickness, previous bad experiences with nausea and vomiting, being young, having a history of heavy alcohol intake and being a women of menstrual age.
The following are helpful tips to control nausea and vomiting associated with chemotherapy:
- Drink liquids at least one hour before or after meals, instead of with your meal.
- Eat and drink slowly.
- Eat several small meals throughout the day, instead of one, two, or three larger meals.
- Breathe deeply and slowly when you feel nauseated.
- Avoid sweet, fried, greasy, or fatty foods.
- Rest, but do not lie flat for at least two hours after a meal.
- Try ginger tablets or ginger ale; ginger has been reported to reduce feelings of nausea.
- Wear loose-fitting clothes
- Practice relaxation techniques and seek complementary medicine intervention such as acupuncture.
Highly effective drugs have been developed to control chemotherapy associated nausea and vomiting. The most effective drug or combination of drugs as judged by your physician at OC Blood & Cancer Care will be prescribed to you:
These drugs include the following:
- Lorazepam (Ativan)
- Prochlorperazine (Compazine)
- Metoclopramide ( Reglan)
- Dexamethasone (Decadron)
- Ondansetron (Zofran)
- Granisetron (Kytril)
Chemotherapy drugs can damage nerves, most often in the fingers and toes, which leads to burning, numbness, tingling, shooting pain, constipation or pain/cramping in the limbs. The most common drug offenders include paclitaxel, docetaxel, cisplatinum, vincristine and oxaliplatin. Predisposing conditions to chemotherapy induced neuropathy include preexisting neuropathy from any cause, diabetes, alcoholism or malnutrition.
Steps can be taken to relieve neuropathy if it develops so notify your physician at the earliest onset. There are many different medications and methods to help control the problem.
Not all chemotherapeutic drugs cause hair loss so ask your physician. Hair loss usually occurs between 10 and 21 days after drug administration. It may happen suddenly and in large amounts or hair may fall out very gradually. The fall out can be a function of the rate of growth of your hair. It is a temporary problem and hair should grow back after treatment is stopped.
Things you can do to help care for your scalp and hair include using a mild shampoo and soft hair brush; practice gentle scalp care (low heat drying, avoid perming, dying or relaxing your hair, and use sunscreen/scalp protection.
Although not life-threatening, hair loss can be very distressing. Many people buy a wig or hairpiece, or use hats or scarves, to cover their head. If you buy a wig because of cancer treatment, it is a tax-deductible expense and may be covered in part by health insurance. The American Cancer Society office located on our campus has a very large wig bank and we urge to visit them.
Neutropenia, Anemia and Thrombocytopenia (Low Blood counts)
One of the most common side effects of chemotherapy is suppression of the bone marrow, the factory of blood cells (white cells, red cells and platelets), which results in neutropenia (low white blood cells), anemia (low red blood cells) and thrombocytopenia (low platelets).
Blood cell counts do not drop immediately after starting chemotherapy because the drugs do not kill cells already in the blood stream. Chemotherapeutic drugs, instead, prevent bone marrow from forming new blood cells. Each type of blood cell has an average life span, which has an impact on when each type of blood cell reaches its lowest levels, called the nadir.
Typically you will be required to obtain a complete blood count (CBC) before chemotherapy is administered to you to ensure it is safe for you to receive treatment. If your WBC/neutrophils, platelets or red cells are too low, treatment may be delayed, held or reduced.
Neutropenia: Blood normally has between 4,000 and 10,000 WBCs per cubic millimeter (45-70% of these cells are neutrophils). The main function of white blood cells/neutrophils is to help prevent and fight infection. Because the white blood cells play such an important we monitor your white blood cell level very carefully. When your white blood cell count falls, it is known as neutropenia. If your WBC count falls, you will not automatically get an infection but you will be more susceptible to infection, which is a serious problem. Thus, it is important to watch for signs and symptoms of a possible infection such as fever, shaking chills, sore throat, confusion, shortness of breath, new cough, nasal congestion, burning sensation during urination, redness, swelling, and warmth at site of an injury or diarrhea.
Commercially available growth factors stimulate the production of different types of blood cells and help shorten the duration of neutropenia. The two growth factors that stimulate production of white blood cells in the body is granulocyte-macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF). Luekine is recombinant GM-CSF and Neupogen (filgastrim) is recombinant G-CSF. Both drugs are administered subcutaneously after chemotherapy on a daily basis until WBC recovery (schedule varies). Neulasta (peg-filgastrim) is a long acting form of neupogen and is only administered once subcutaenously the day after chemotherapy.
There are things you can do to decrease your risk of infection:
- Wash your hands often during the day (before you eat, after going to the bathroom, and after touching animals).
- Stay away from people who have illnesses that you can catch, like a cold, the flu, or chicken pox.
Try to avoid crowds.
- Stay away from children who have recently received “live virus” vaccines, like chickenpox or oral polio.
- Maintain good mouth care.
- Do not eat raw fish, seafood, meat, or eggs.
- Clean cuts and scrapes right away and daily until healed.
- Report any signs of infection to your doctor immediately.
Anemia: Hemoglobin of less than 12 gm/dl for the context of this discussion defines anemia or low red blood cell (hemoglobin is another way to look at it). Red cells function to carry oxygen throughout the body. If anemia develops you may experience the following: fatigue, dizziness, feeling faint, shortness of breath, feeling a “pounding” heart or palpitations, chest pain or headache.
If such symptoms develop and are attributed to anemia you may be recommended a growth factor for red cells called erythropoietin (Procrit, Epogen); iron supplementation and/or red blood cell transfusion therapy
Thrombocytopenia: The normal range for the platelet count is between 150,000 and 450,000 per cubic millimeter. Platelets function to help stop bleeding and augment blood clotting. The risk of bleeding significantly increases when the platelet count falls below 50,000 and increases incrementally thereafter. The risk is also heightened if you are taking medications that poison platelets (aspirin, ibuprofen, Plavix, Effient, etc), supplements such as flaxseed oil which impair platelet function or medications that thin your blood (Coumadin, Lovenox,etc).
Signs that your platelet count may be low include the following: easy bruising, heavy or longer menstrual period, bleeding longer than usual after minor cuts or scrapes, bleeding gums or nose bleeds, developing large bruises and multiple small bruises (petechiae).
Treatment for thrombocytopenia varies and includes avoidance of trauma including intramuscular injections; holding, dose reducing or delaying chemotherapy and platelet transfusion therapy.
Lack of Appetite
Cancer itself as well as chemotherapy may cause a decreased or complete loss of appetite with resultant weight loss. The severity can range from mild to severe and may lead to malnutrition. The decrease in appetite is usually temporary and your appetite should return after chemotherapy has stopped, but it may take several weeks. Because chemotherapy can alter your sensation of taste, the therapy can affect the way some foods taste and smell to you, adding to your poor appetite and weight loss. Your taste and smell should also return to normal several weeks after chemotherapy has ended.
Weight loss and malnutrition should be avoided. Indeed, adequate nutrition is required by your body to fight the cancer and cope with chemotherapy and its side effects. Several prescribed appetite stimulants are available.
There are some things you can do to boost your nutritional status:
- Eat small, frequent meals throughout the course of the day.
- Avoid drinking fluids with meals to prevent from feeling full (again focus on high calorie/high protein foods).
- Eat foods high in protein, such as eggs, peanut butter, nuts, dairy products, tuna, and beans.
- Breakfast may be the most tolerable meal of the day; try to include at least one-third of your calories in this meal.
- Monitor and record your weight weekly; tell your doctor of any changes.
Mucositis, Head & Neck Cancer Supportive Treatment
Some chemotherapy drugs and radiation treatments can damage the lining of the mouth and throat down to the lower gastrointestinal tract. Such damage leads to inflammation, pain, ulceration and sores in the mouth, known as stomatitis, the throat, known as pharyngitis, the esophagus, known as esophagitis, the stomach, known as gastritis, and so forth.
Mucositis is a general term used to refer to inflammation and damage of any part or the entire gastrointestinal tract. Mucositis affecting the mouth and throat is very common with treatment for head and neck cancer and requires close attention and a dedicated multidisciplinary treatment team. It is caused by the damaging effects of chemotherapy and radiation which are typically given together for the aforementioned disease.
Symptoms and severity of mucositis vary and can include mouth and throat pain, difficulty swallowing, swollen gums, ulcerations, redness, sores, inability to eat (with resultant weight loss), increased mucus which is thick, nausea, fever, vomiting, pus or white plaques in the mouth, diarrhea and abdominal cramping. While mucositis is present the barriers or defense mechanisms against bacteria, fungus and yeast are breached and thus secondary infection may occur.
Factors that can increase the likelihood of developing mucositis, or that can increase the severity include poor oral or dental health, smoking or chewing tobacco, drinking alcohol, dehydration, diseases such as kidney disease, diabetes or HIV/AIDS, malnutrition, chronic irritation from ill-fitting prostheses or faulty restorations, concurrent oral viral or fungal infections.
Oral mucositis generally begins 5-10 days following the initiation of chemotherapy and lasts anywhere from one week to six weeks or more. Resolution usually coincides with recovery of the white blood cell count if chemotherapy is the cause or with the completion of radiation therapy.
- Complete dental evaluation and care; if you wear dentures, you will need to make sure they fit properly. If any work is needed (tooth extractions or refitting of dentures), it should be completed at least one month prior to starting therapy.
- Use mouth rinses regularly and daily (salt water rinses).
- Avoid alcohol and irritating foods, such as those that are spicy, hot, acidic or coarse.
- Use a soft bristle toothbrush and brush your teeth after eating 2 to 3 times each day. You should use a mild tasting toothpaste with fluoride, such as Biotene enzyme based products, as some flavorings and foaming agents such as SLS in toothpaste may irritate the mouth. You may augment these with Rx strength fluoride ones such as Prevident from Colgate.
- You should gently floss your teeth once daily.
- Rinse mouth (swish and spit) before and after meals and at bedtime with either salt water (1 tsp of table salt to 1 quart of water), or salt and soda (one-half teaspoon of salt and 2 tablespoons of sodium bicarbonate in 1 quart of warm water).
- If you smoke, it is extremely important that you stop.
- Avoid products that irritate the mouth and gums, such as strong flavored commercial mouthwashes and those with alcohol.
- Keep lips moist with moisturizers. Avoid using Vaseline (the oil base can promote infection).
- Increase your fluid intake.
- Try to include foods high in protein in your diet.
- If you wear dentures, remove them whenever possible to expose gums to air. Loose fitting dentures can irritate the mouth and gums and should not be worn. Do not wear dentures if mouth sores are severe.
- Sucking on ice chips during chemotherapy administration, has shown some effect in preventing mucositis caused by 5-FU (fluorouracil).
- Your physician will consider the use of Gelclair and Zilactin, which are mucosal protectants that work by coating the mucosa and forming a protective barrier.
- Specifically, in the case of head and neck cancer your physician will consider Amifostine (Ethyol), a drug that offers some protection against the damage to the mucosa caused by radiation. Other agents that have been studied in this population of patients include: capsaicin (derived from chili peppers), glutamine, prostaglandin E2, Vitamin E, sucralfate, and allopurinol mouthwash with varying degrees of success.
- Use antacid such as ranitidine or omeprazole.
- In the case of patients undergoing marrow/stem cell transplantation, the use of palifermin, a recombinant keratinocyte growth factor, should be considered.
- Increase brushing (with the softest tooth brush possible) to every 4 hours and at bedtime. It is important to brush and floss very gently.
- Rinse your mouth frequently with antiseptic mouth rinses, such as Peridex or Periogard. You can also make your own rinse by mixing 1 teaspoon of baking soda in 8 ounces of water or ½ teaspoon salt and 2 tablespoons of sodium bicarbonate dissolved in 4 cups of water. This solution can also reduce some of the severe phlegm / mucous production that is a by-product of the treatments.
- Saliva production will decrease on therapy for head and neck cancer which will cause xerostomia (dry mouth). Chewing ice chips, chewing sugarless gum, or sucking tart sugar free candy to increase moisture. Artificial saliva products can also be used.
- Over-the-counter products are available such as enzyme based Oral Balance, Biotene toothpaste and mouthwash that are free of the strong flavors and foaming agents that can be very irritating to sensitive tissues under treatment. Since your saliva barrier is compromised, you should avoid eating or drinking products containing sugar to prevent cavities.
- To help clean oral sores you can rinse with a solution consisting of 1 part of 3% hydrogen peroxide with 2 parts of saltwater (1 teaspoon of salt dissolved in 4 cups of water). For mild fungal infections, topical oral suspensions or dissolving tablets can be prescribed that contain anti-fungals. You will need to swish or dissolve the medicine in your mouth and, depending on your doctor’s directions, either swallow or spit out the medicine. Also, if you wear any dental appliances, you should soak them in antiseptic solutions.
- In mild cases of pain, ice pops, water ice, or ice chips may help numb the area. If more local pain control is required Topical pain relievers include lidocaine, benzocaine, dyclonine hydrochloride (HCl), and Ulcerease® (0.6% Phenol).
- Corticosteroids such as prednisone may be effective also in pain relief.
- Benadry elixir, lozenges and analgesics may help reduce mouth pain.
- Swishing and gargling the anesthetic gel viscous Xylocaine 2% can help you eat if you have pain in your mouth, pharynx or esophagus. Use 1 tsp.(5 mL) viscous Xylocaine before meals. (Hold in mouth for one minute, then spit out.) This may increase your ability to eat by mouth while the anesthetic effects are working.
- Cepacol Lozenges, Chloraseptic spray and lozenges, or the use of tea (particularly chamomile) for swishing and gargling may be of some help.
- Biotene mouthwashes, which combine enzyme based protection and soothing mouth moisturizers are available over the counter.
- Swish diluted milk of magnesia, Carafate slurry or Mylanta around your mouth. Orabase B is an over-the-counter agent that is an adhesive paste with a topical anesthetic (benzocaine) that may be helpful.
- You can also use topical products like Orajel or some prescription products like viscous lidocaine to eliviate discomfort temporarily.
- A common topical agent is a so-called “magic mouthwash”. Some patients report good results with a combination of Lidocaine (a numbing agent), Benadryl, Maalox, and Nystatin (an antifungal).
- Advil, Tylenol and narcotic pain killers are often required to ease pain/discomfort. Indeed adequate pain relief is essential as the lining of the mouth and gastrointestinal tract heal.
Reproduction and Sexual Problems
Chemotherapy can cause reproductive and sexual problems. Whether or not you experience these changes will depend on factors such as your age, which chemotherapy drug you are exposed to as well as the dose and duration of treatment. Again, each patient may experience different side effects or none at all.
An important issue is fertility preservation in young patients cured of their cancer. Your physician at OC Blood & Cancer Care can counsel you about this potential problem as well as available options to maintain fertility.
Some reproductive and sexual changes a woman may experience during or after chemotherapy include the following:
- Temporary or permanent damage to the ovaries
- Disruption or stoppage of the menstrual cycle
- Symptoms of early menopause, such as hot flashes, vaginal dryness, and tightness during intercourse
- Irritation and dryness of the lining of the vagina
- Vaginal infections
- Some reproductive and sexual changes a man may experience during or after therapy include the following:
- Decrease in sexual desire
- Difficulty getting and maintaining an erection
- Damage to sperm
- Permanent sterility