Many times patients experience symptoms that can be attributable to their cancer or to their treatments. It is important to know that not all patients experience even the “common” side effects and the extent of the side effects vary considerable. Below are some of the side effects that some patients experience and some tips about them. There are ways to treat or mitigate many of the side effects, so do not suffer in silence. The overriding point is to promptly advise your physicians of any side effects and be vigilant in seeking ways to minimize them.
Chemo brain: Many patients experience some cognitive difficulties, which is now commonly referred to as chemo brain. For years, medical professionals did not acknowledge the existence of chemo brain, but in recent years this has received much greater attention. Symptoms can include some difficulties with memory, concentration, and fogginess, finding the right words, and processing information. The cause is unknown, but generally the symptoms are relatively minor and usually dissipate after treatment and disappear over time. Only a small percentage of patients have long-term cognitive impairment. If you have trouble focusing or with your memory, write down reminders to yourself, place items such as house car keys, cell phones and planners in the same place, and allow some additional time to accomplish tasks. Discuss your symptoms with your health care team. Metformin, a drug used to treat diabetes and showing early promise as a cancer treatment (particularly in reducing relapse rates), may be a potentially useful drug in treating chemo brain.
Low blood counts: It is common for patients going through treatment to have low blood counts (red, white, and platelets). This sometimes is the intended result of chemotherapy. Years ago, more patients had to delay or interrupt their treatments because their counts were too low and more patients acquired infections. Fortunately, a category of drugs called growth factors can stimulate your bone marrow to make new white cells. Commonly used growth factors include filgrastim (Neupogen), pegfilgrastim (Neulasta), G-CSF (granulocyte colony-stimulating factor), GM-CSF (granulocyte-macrophage colony-stimulating factor); and sargramostim (Leukine). In some instances, patients may require a blood transfusion.
Infection: As a result of low white counts and compromised immune systems, patients are particularly vulnerable to infection at least at some points during their treatment. Patients may be given antibiotics to prevent or treat infection. It is important to take all steps to avoid infection, including washing your hands regularly and thoroughly, making sure your health care providers and others you are in contact with wash their hands and, where appropriate, where masks and gowns. Avoid sick people, crowds, cuts, uncooked foods, and consider avoiding air travel. If you are receiving chemotherapy or other drugs through a central line or port, make sure catheters are cleaned meticulously. Watch for signs of infection such as a temperature, chills, persistent coughing, tenderness or redness, pain while urinating, or diarrhea. Notify your physician immediately. Ask your physician about which vaccines you should and should not receive.
Anemia: Anemia is caused by a low red cell count, potentially resulting in fatigue, shortness of breath, pale skin, gums or nails, light-headedness or dizziness, and/or a tendency to feel cold. Your health care team should monitor your counts and you should as well and adjust your diet. Red cell growth factors such as Epogen, Procrit, or Aranesp may be prescribed or a blood transfusion may be required. It is important to discuss with your physician the risks and benefits of this therapy.
Bleeding: Severally low platelet counts may cause excessive bleeding from cuts or bruises, pinhead-sized bleeding points in the skin (petechiae), black-and-blue spots on the skin from minor bumps without any apparent injury, reddish or pinkish urine, black or bloody bowel movements, bleeding from the gums or nose, headaches, weakness, and join or muscle pain. Once the platelet count is restored these side effects usually rapidly fade. Certain medications can weaken the platelets and worsen bleeding problems as well. Ask your physician whether it is safe for you to take aspirin, acetaminophen, or ibuprofen. Avoid alcohol, use a soft toothbrush and brush gently, and avoid cuts and activities that might result in trauma or injury.
Hair loss: Hairy loss or alopecia is a common side effect of chemotherapy, but not all patients loss their hair. The extent to which patients experience hair loss or thinning depends upon the specific drugs, the dosages, and the individual patient. Hair loss does not occur with all drugs. Hair follicles are sensitive to chemotherapy because like cancer cells they multiple rapidly, but they will repair so the effects are temporary. Hair loss usually is not limited to the head and often takes place after the first cycle or two of chemotherapy and it will begin to grow back after completion of chemo and often before.
Generally, the new hair looks like the old, but sometimes the color, texture, or curl may be a little different. Some patients have attempted to reduce hair loss by using tight bands or ice caps, with mixed results at best. During chemotherapy, some patients cut their hair short, wear wigs, or wear caps and scarves. This is a matter of personal preference. Remember to protect your scalp from exposure to the sun. The results of a small prospective cohort study suggest that wearing a scalp-cooling cap can reduce hair loss in women receiving chemotherapy for breast cancer. Among women who used the cooling headgear starting 20 minutes before chemotherapy and continuing for 60-90 minutes after the infusion, 24% did not wear a wig or headband upon completion of chemotherapy, compared with 4% of a control group that did not have access to the device. But additional research is needed to look at effectiveness as well as side effects from using the cooling devise.
Cancer-related fatigue: The majority of cancer patients experience fatigue to some extent. There is no panacea for fatigue, but many patients find that exercise, a good diet, drinking plenty of liquids (e.g., water) to get rid of toxins helps reduce fatigue. Counseling, stress management, coping strategies, and other psychosocial interventions that reduce stress and increase psychosocial support can help reduce fatigue and increase energy levels. Randomized trials have shown that cognitive behavioral strategies such as progressive muscle relaxation or relaxation breathing may reduce fatigue in those receiving radiation therapy or hematopoietic stem cell transplantation. Medications play a role in managing fatigue, but there is no consensus about which drugs are useful. Erythropoiesis stimulating agents (which stimulate the body to make red cells) may be prescribed for anemia; psychostimulants such as methylphenidate (Ritalin or Methylin) or dexmethylphenidate (Focalin); antidepressants, and corticosteroids are sometimes used depending upon the perceived caused and symptoms. All of these medications have potential side effects and the patient and physician must weigh the benefits and risks.
Some useful coping strategies include: being flexible and set realistic goals factoring in the rigors of treatment and how you feel; prioritize and ask for help from family and friends; and schedule treatments for those times that will have the least effect on your job and activities. Fatigue among cancer survivors may be driven by changes in cytokines and stress hormones that contribute to inflammation. Thus, reducing inflammation in these patients could reduce fatigue. In a study of 633 breast cancer survivors, higher intake of omega-3 polyunsaturated fatty acids was linked with decreased inflammation (lower C-reactive protein levels) and decreased physical fatigue. Higher intake of omega-6 PUFA relative to omega-3 PUFA was significantly associated with higher CRP levels and greater likelihood of fatigue.
Diarrhea: Some anticancer drugs affect normal cells in the gastrointestinal tract by causing diarrhea. If diarrhea occurs, your doctor may prescribe antidiarrheal drugs, antibiotics, intravenous fluids or changes in diet. Drinking water may help. Avoid caffeinated beverages (coffee, tea and certain soft drinks), alcohol, and milk.
Constipation: Some drugs may cause or intensify constipation. Your physician may recommend laxatives, intravenous fluids, or changes in diet. Drinking warm or hot fluids may help.
Nausea and vomiting: Cancer treatment can irritate the gastrointestinal tract as well as stimulate an area of the brain that affects the gastrointestinal tract. The frequency and severity of nausea and vomiting vary among patients. Sometimes nausea and vomiting subside as you adjust to treatment. There are several medications available that help with nausea caused by chemotherapy treatments, including: Emend (aprepitant), Zofran (ondansetron), Reglan (metoclopramide), Kytril (granisetron), Anzemet (dolasetron), and Aloxi (palonosetron). However, a 2012 clinical trial showed that the antipsychotic drug olanzapine (Zyprexa) performed much better than the standard treatments for chemotherapy-induced nausea and vomiting. In the double-blind phase III study, 30 (71%) of 42 patients, who received olanzapine had no emesis (vomiting) compared with 12 (32%) of 38 patients who received metoclopramide (Reglan) during a 72-hour observation period after chemotherapy. In addition, 28 (67%) of patients on olanzapine had no nausea, compared with nine (24% ) of those patients on metoclopramide. Temporary weight gain may be associated with olanzapine. Some patients find that acupuncture and therapeutic massage can help manage or relieve nausea and vomiting. A steroid called Dexamethasone has been shown to prevent radiation-induced vomiting, especially in treatment of cancers of the abdomen.
Mouth sores and other mouth symptoms: The lining of your mouth and throat are particularly susceptible to damage from cancer treatment. Mouth sores (ulcers) or cold sores; a burning sensation or pain in the mouth or throat (stomatitis); a decrease in saliva during treatment; a red and swollen tongue; a stinging sensation in the throat or difficulty swallowing (dysphagia), a white coating or patches on the tongue, inside of the cheeks or floor of the mouth (candidiasis), which may suggest a yeast infection; and dry, cracked, sore or bleeding lips are among the potential mouth-related symptoms. Xerostomia is a chronic dry-mouth condition caused by damage from radiation therapy to the salivary glands. Amifostine is a radiation protector and the only drug that has been approved by the FDA for xerostomia in patients receiving radiation therapy for cancers of the head and neck. The topical agent sucralfate may protect mucous membranes and is often used during and after radiation therapy to prevent and treat mucositis or mouth sores. Topical antiseptics, such as chlorhexidine and benzydamine, have been used for the prevention of mucositis, but recent studies suggest these may not be effective. In one German study, patients treated with chlorhexidine actually seemed to have more problems with inflammation, resulting in mucositis.
Difficulty swallowing: Some of the following may be helpful if you are experiencing difficulty in swallowing: gargle with baby aspirin pills dissolved in lukewarm water which can reduce inflammation in your throat and esophagus; drink hot honey and lemon tea which can soothe the throat while trying to swallow pills or food; use lozenges, gels, sprays and rinses to replace saliva where lack of saliva is making swallowing difficult; eat soft, smooth foods, such as yogurt, pudding, or ice cream; mash or blend foods, or moisten dry foods with broth, sauce, butter, or milk and avoid dry foods and bread; thicken liquids by adding gelatin, tapioca, baby rice cereal, or commercial thickening products; use a straw to drink liquids and soft foods; eat foods that are cold (to help numb pain) or at room temperature; take extra small and chew slowly and thoroughly; drink with meals; and sit upright when eating or drinking.
Pain: Bone and muscle pain may be related to your cancer, its treatment, or other coexisting diseases such as arthritis. The proper approach depends upon the cause, severity, and frequency of the pain as well as balancing the benefits and side-effects of treating the pain. Pain assessment is an important part of any medical evaluation, and pain management is an important part of care. Left untreated, pain can suppress the immune system, delay healing and lead to depression. Many patients experience partial relief from pain though a variety of non-drug therapies. Some of these include: physical therapy and rehabilitation; meditation, hypnosis, electrical nerve stimulation guided imagery, herbs, special diets, vitamins; massage, chiropractic manipulation, acupuncture, exercise (such as walking or pool therapy); and hot or cold packs. There are a range of medications, including non-steroidal anti-inflammatory drugs, acetaminophen, opioid analgesics, antidepressant and anticonvulsant drugs, nerve blocks, corticosteroids, anesthetics; specialized injections, infusions, topical creams and skin patches. Talk to your health care providers regarding your pain and ways to reduce it.
Depression, anxiety, and stress: These not only normal responses to a cancer diagnosis and treatment, someone would have to be crazy not to experience some level of depression, anxiety, and stress under these circumstances. You may feel overwhelmed by your cancer and that your life has been overtaken by treatment. Certain anticancer medications may contribute to feelings of anxiety and symptoms of depression. Where your experience with any of these conditions is prolonged or severe, make sure you get help. These conditions are no less harmless and no less worthy or treatment than pain.
Peripheral neuropathy: Cancer treatment or sometimes the disease itself can cause peripheral neuropathy, which is damage to nerves of the peripheral nervous system, which transmits information from the brain and spinal cord to other parts of the body. Chemotherapy-induced peripheral neuropathy affects between 30% and 40% of patients receiving cancer treatment. Chemotherapy agents most commonly linked to peripheral neuropathy are taxanes (paclitaxel, docetaxel), platinum agents (carboplatin, cisplatin, oxaliplatin), vinca alkaloids (vincristine, vinblastine), bortezomib (velcade), and thalidomide.
It can manifest in numbness, tingling, burning, coldness, weakness, and/or temperature sensitivity especially in the fingers, toes, hands, and feet. Individuals at greatest risk of peripheral neuropathy associated with chemotherapy are those with preexisting peripheral neuropathy from conditions such as diabetes or immune disorders and people who previously have received chemotherapy. The patient’s age, duration of treatment, dosage, and administration of other neurotoxic drugs also are factors. It is critical that you let your physician know if you are experiencing neuropathy as it must be closely monitored and adjustments to treatments such as changing agents or dosages or may be required.
Your physician may prescribe certain medications and vitamins to help prevent or lesson neuropathy. Tricyclic antidepressants and anticonvulsants showed some initial promise, but further investigations have failed to demonstrate that these agents cause any alleviation of painful symptoms. Most drugs that have been effective for diabetic neuropathy have not proven to be effective for chemotherapy-induced peripheral neuropathy.
Several other treatments currently being investigated suggest some benefit for patients, although additional larger trials are needed. Some of these drugs include: baclofen, amitriptyline, and ketamine in a pluronic lecithin, venlafaxine (Effexor) and duloxetine (Cymbalta). Scrambler therapy is a novel approach to pain control that attempt to relieve pain by providing “non-pain” information via cutaneous nerves to block the effect of pain information. It has shown effectiveness in some patients. Electrostimulation and acupuncture have been reported by some patients to lesson symptoms. In terms of prevention, intravenous administration of calcium and magnesium, before and after oxaliplatin-based treatment regimens, has been shown in several studies to prevent neurotoxicity. Other agents that may prove beneficial in preventing chemotherapy-induced neuropathy are acetyl-L-carnitine, glutamine, glutathione, and N-acetylcysteine, but additional research is needed. Chemotherapy induced neuropathy may gradually decrease after you complete therapy. Many people recover fully from neuropathy, but in some cases the symptoms may persist.