A question I hear nearly every day – “How sick will the treatments make me?”  Almost every person has heard horror stories of a patient’s suffering during chemotherapy.  Some patients who could have their lives prolonged refuse treatment because of their fear of side effects.

            How realistic are these concerns?  What can be done to ameliorate (lessen) the toxicity of treatment?

            Lets look at some of the common side effects of these powerful and often effective medicines. 

            1.  NAUSEA AND VOMITING.   Not all cancer drugs are emetogenic (able to cause vomiting), but many are.  In the last few years several antiemetic (anti-nausea) drugs have been developed.  Several of the most effective are Aloxi, Zofran, Kytril and Anzemet.  These drugs can be given intravenously (IV, in the vein) or orally (except for Aloxi).  Emend is an oral drug that prevents the delayed nausea seen with several drugs.  It belongs to a new class of drugs and is a major advance in symptom management.  Use of these drugs prevents vomiting in more than 90% of cancer patients.  Other drugs (such as Compazine, Decadron, Phenergan or Reglan) or techniques (such as hypnosis) may be used for some patients. 

            Nausea, if it occurs, generally begins within a few hours of treatment and lasts up to 12 hours.  A few drugs (most notably Cisplatinum, used for several cancers including ovarian and lung cancer) have delayed emesis (vomiting).  This is due to its long half-life (amount of time it circulates in the body).  Your oncologist may well instruct you to take your antiemetic for several doses on a schedule even if you feel well.

            A few patients begin to feel nauseated even before the drug is infused.  This is called anticipatory nausea.  Anticipatory nausea is poorly responsive to antiemetics, but often responds to hypnosis, mediation or other relaxations techniques.

            Patients also may help themselves by avoiding fatty, greasy food and food with a strong odor. 

            Patients who start chemotherapy with the conviction that they will be sick often are!  Enter treatment with a positive attitude and you may well be surprised at how well you do. 

            2.  ALOPECIA (HAIR LOSS).  The alopecia which often results from treatment is not currently preventable.  Hair loss (when it occurs – again some chemotherapeutic agents do not cause hair loss) usually begins about two weeks after the first treatment.  Few patients realize how devastated they will be by the hair loss.  Invest in an attractive comfortable wig.  Select it before you lose your hair.  Hair regrowth starts three to four weeks after the end of treatment.  Sometimes the hair is a different shade or texture than it was originally.  However, I’ve never had a patient complain about their regrown hair. 

            3.  LOW BLOOD COUNTS.  A CBC (complete blood count) includes a measurement of the hemoglobin (which carries oxygen and gives blood its red color), the white cells (which fight infection), and the platelets (which help the blood clot).  Most chemotherapeutic drugs cause a decrease in these blood counts.  The most common and serious problem is with a low white count and resultant increase risk of infection. 

            Your doctor will check your CBC and let you know if the counts are low enough that you need to take special precautions to prevent infection.  These safety measures are mainly common sense, such as staying out of crowds, away from sick people and small children, and avoiding skin cuts, which would allow bacteria (germs) to enter the body.  When your white count is very low, fresh fruits and vegetables (which harbor bacteria from the soil) should not be eaten.  (If you can’t cook it or peel it, don’t eat it.)  When your diet is restricted, your oncology nurse will work with you to ensure you are receiving all the nutrients (foods) that you need.

            Low white blood and platelet counts usually occur about 10 days after treatment and require 4 to 10 days to improve. 

            Now we have three drugs, Neulasta, Neupogen and Leukine, which send a message to the bone marrow (the inside of the bone where these cells are made) that says, “Please make me some white cells.”  Neulasta is used before the white count has fallen to prevent the fall.  This both lessens the chance of infection and helps ensure that subsequent treatments are delivered in a timely fashion.  These very effective drugs allow use of high doses of chemotherapeutic drugs.  Epogen and Aranesp stimulate production of hemoglobin.  These two drugs are given weekly or every other week by subcutaneous (under the skin) injection.  Neumega serves the function of stimulating platelet production. 

            4.  FATIGUE.  Fatigue is common during cancer treatment.  Causes of fatigue are

many.  One correctable one is anemia (low hemoglobin).  Epogen (Procrit) or Aranesp, by

raising the level of hemoglobin, is often helpful.  Fatigue is also managed by increased rest and

some limitation of activity. However, don’t “take to the bed”! An exercise program is important. 

Many patients find fatigue the most difficult part of cancer treatment.  It is important that the

patient’s family and friends realize that the fatigue is “real” and not “just depression”.  During

this period help with the housework, meal preparation, shopping, yard work, trips to the doctor,

and other activities is greatly appreciated and is a concrete way that care and concern can be

shown. 

5.  WEIGHT CHANGES.  Cancer, by a means which is poorly understood, often causes weight loss.  Most patients find the anorexia (loss of appetite) and resultant weight loss disturbing.  Now there are several drugs, such as Megace, Marinol and Oxandrin that stimulate appetite in cancer patients.  In addition, your chemotherapy certified nurses have been trained to offer suggestions regarding nutrition.  Pamphlets are available in your oncologist’s office on “Eating Hints”.  Chemotherapy rarely induces weight loss; actually 25% of women treated adjuvantly for breast cancer gain 10% or more of their baseline body weight.

6.  MUCOSITIS (MOUTH SORES).  Mucositis may occur with a few drugs.  This side effect can be treated with special mouthwashes. Avoid foods that are acidic and select those that are soft, such as oatmeal, ice cream, mashed potatoes and scrambled eggs.  Use good oral hygiene to reduce the bacteria content in your mouth.  Choose a nonalcoholic mouthwash and use it consistently.  A visit to the dentist prior to starting treatment is a good idea.  Remove your dentures except for meals.  Make sure they fit well. 

            7.  DIARRHEA.  Diarrhea is a common problem with two of the most effective drugs used to treat colorectal cancer (5-FU and Camptosar).  It is not common with most other drugs.  Drugs such as Imodium and Lomotil may be used.  Dietary changes such as a low residue diet may help.  A BRAT (banana, rice, applesauce and toast) diet may be suggested.  Ask for specific instructions from your oncology nurse.     

8.  SKIN.  Some drugs make you much more likely to get a sunburn.  You may be cautioned not to go outside without a hat and sunscreen of SPF 15 or greater.  A few drugs (most notably 5-FU and Taxotere) can cause the skin and nails to darken.  Several drugs, including Navelbine, cause the vein used for their injection to become dark all the way to the elbow or (occasionally) to the shoulder.  This dark color will fade over several months. 

         Extravasation is a serious problem with some drugs.  Extravasation occurs when the drug leaks out of the vein and into the surrounding tissue.  Some drugs (vesicants) can cause necrosis (cell death) of any tissues they touch.  The “worst offenders” are Adriamycin (used for breast cancer and lymphoma) and Nitrogen Mustard (used for Hodgkin's disease).  Extravasation by one of these drugs may require skin grafting.  By law only MDs and specially trained nurses (chemotherapy certified RNs) can give these drugs.  Be sure to tell your nurse immediately if pain occurs during drug administration. 

            9.  REPRODUCTIVE SYSTEM.  Many of these powerful drugs can affect the fertility of both men and women.  Cancer is usually a disease of older patients, and often they have completed their families.  For those who haven’t, sperm banking is available for men.  Recently ovarian banking has become available for women.  Of course, pregnancy is absolutely contraindicated during chemotherapy, as these drugs are teratogenic (cause severe damage to the baby).

            Menopause is often precipitated by these drugs.  The probability of this side effect is dependent on the type of drug and the woman’s age.    

10.  OTHER.  Many drugs have specific side effects.  For example, Taxol (used for breast cancer, ovarian cancer and lung cancer) can cause anaphylaxis (a severe allergic reaction) and Adriamycin (used for breast cancer) can cause heart damage. Taxotere (used for breast and lung cancer) can cause the eyes to water. Your oncologist will discuss the specific toxicities of the drugs he or she suggests using. 

11.  OTHER HINTS.  Your oncologist and your chemotherapy nurse will be as specific as possible when teaching you about the drugs recommended for you.  Educational material such as books, videotapes, and pamphlets are available in your doctor’s office.  Your oncology nurse will be able to give you a list of support groups available locally.  Spirit counts.  A positive state of mind and a determination to prevail against the illness are important.  Many patients report that prayer and/or meditation has played a role in their recovery. 

12.  CHOICES.  If you have metastatic cancer (cancer that has spread to several areas of the body), the choice is not between treatment and a good quality of life; but is between treatment with hope of response versus the certain progression of your illness with all its symptoms.  Several studies have shown that patients who receive chemotherapy for metastatic cancer have a better quality of life than those who receive supportive care only.  The worst “side effects” of all are those of an advancing cancer. 

            Requesting a second opinion is fine.  No doctor enjoys treating a patient who harbors doubts.  Since it is more convenient to be treated “at home” patients usually return to Anniston.  All FDA-approved oncology agents are available here. 

            Most chemotherapy is given in an office setting.  This allows drugs to be prepared “on site” and decreases waiting time.  Patients often socialize with each other during treatment. 

            Coping with a serious illness is a “team event” and requires your active participation.  The “best patient” is an informed and committed patient.