Download Chemotherapy Side Effects And Their Management (part 1)

Chemotherapy Side Effects And Their Management (part 1)
An educational article for cancer patients and caregivers presenting scientific facts about
chemotherapy toxicities, and addressing fears, myths and actual concerns before, during and after
chemotherapy
Article intended to educate patients and relatives, but not intended to replace a detailed prechemotherapy counselling by treating Medical oncologist. Suggestions put forward are helpful in
toxicity management at home but cannot replace treating onco-physician’s or onco-nurse’s
guidance.
Dr RavindraVottery
Introduction To Chemotherapy Side Effects
The word chemotherapy frightens most patients and their families. Friends, colleagues, neighbours
and relatives tell stories about “chemo” which do the rounds and instil within minds of patients,
morbid fear and a preconceived notion about the futility and dangers of chemotherapy.
The best way of allaying fear is by knowing in depth or actually facing the object one is afraid of. Fear
is in the mind. Only danger is real.
Human body is made up of 75-100 trillion cells. Cancers or tumors arise due to unregulated cell
multiplication. The cancer is named based on the organ of origin.
Chemotherapy is the broad term applied to all those numerous drugs that stop cancer cells from
multiplying, just like antibacterial chemotherapy stops bacteria from dividing. These drugs inevitably
affect cell division/multiplication in normal organs, giving rise to “side by side” effects or toxicities.
Fear of side effects should not deter a cancer patient from agreeing to receive chemotherapy or
completing the specified number of cycles.
Although nowadays many molecularly targeted/ biologic drugs tailor made for specific types of
cancer cells are available, even these have side effects, albeit different and lesser. It will probably
take a long time to design completely nontoxic drugs for all cancers. Please do not wait for that day,
because cancer cells don’t wait for anyone!
WHAT CAUSES THE SIDE EFFECTS OF CHEMOTHERAPY?
1. These drugs are usually corrosive in nature and cause severe pain or even ulcers in case drug
leaks out of the vein.
2. The chemo drugs circulate in the entire body via blood circulation, both after intravenous
injection and after oral administration and gut absorption. Hence toxicities are usually
widespread. Taste of medicine, loss of appetite, tiredness, low stamina, are commonly
reported.
3. They enter the vomiting centre of the brain and trigger vomiting.
4. They kill rapidly dividing cells and thus target not only cancer cells but also bone marrow
cells (marrow makes billions of blood cells daily, hence chemo drugs cause a drop in blood
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counts), hair follicles (root of the hair, causing hair fall), cells lining the layer of pink mucosa
of the mouth, intestines (causing gaps in mucosa called ulcers and then diarrhoea), and
lastly, these drugs affect testes and ovaries (causing temporary menstrual disturbances, low
sperm count).
Many chemotherapy drugs cause special toxicities in particular organs specific to a drug (e.g.
cardiac toxicity, lung, kidney, urinary bladder toxicities, nervous system, ears, skin, nails, liver
toxicity, etc.).
If accidentally given in early pregnancy, chemotherapy drugs, by virtue of their ability to halt
cell multiplication, can kill or badly damage the growing embryo or foetus.
Some patients are allergic to a drug and get a serious reaction. This is unpredictable.
Not to forget…….fear of chemotherapy can cause or aggravate many adverse effects.
ENCOURAGING FACTS ABOUT CHEMOTHERAPY SIDE EFFECTS.
1. Not all patients experience all side effects. Some get none, some get few,only few get many.
2. Severity of the side effect differs from patient to patient with the same drugs, and from drug to
drug. It also depends on the tolerance threshold of the individual. Some patients give plenty of
undue importance to trivial toxicities. Some take them in the stride.
3. Most patients worry about the duration of the side effects. Majority of the toxicities are
temporary, as the healing ability of damaged normal cells is much higher (as these have normal
DNA) than that of the damaged cancer cells (since they have abnormal genetic machinery). And this
is the basis on which these toxic chemotherapy drugs work. Thus all the damage to normal cells
listed above and visible to you as tormenting side effects, vanishes quickly, by the time the next
chemo cycle is due. Be assured that the baldness is temporary.
Much depends on your positive attitude, and the spirit to fight.
4. Even the damage done to organs such as heart, nerves, kidneys, lungs, reproductive organs, etc.
can slowly recover over time. Women regain menses after several months.
Permanent side effects are rare. Good medical oncologists keep looking out for the cumulative organ
damage/ toxicities closely and change the drugs on time.
5. Medical oncologists prescribe drugs to counteract or attenuate the side effects.
6. New drugs with lesser side effects keep coming up for common cancers.
PLEASE REMEMBER……………
The unpleasantness of side effects must always be weighed against the life-saving abilities of
chemotherapy.
And who says drugs used in other branches of medicine do not have side effects?
A drug claimed to be completely devoid of any toxicities may not have any potent or scientifically
designed ingredient, to kill the complex cancer cell!
Please ask your oncologist or onco-nurse to explain you all the important toxicities of the particular
drugs about to be administered. Please sign a written consent.
LET US DEAL WITH THE COMMON CHEMOTHERAPY SIDE EFFECTS
NAUSEA AND VOMITING (EMESIS)
These are not universal side effects, unlike the public opinion. The intensity varies with the actual
drugs, doses, and patients pre-existing excessive sensitivity to tastes and odours.
Some drugs are highly likely to cause vomiting and are blacklisted. Powerful and new anti-vomiting
drugs are anyways prescribed as a standard premedication.
Fortunately, nausea and vomiting occur on the chemo day, and last for a day or less. Only
occasionally is a prolonged or delayed vomiting experienced.
Some sensitive patients develop anticipatory/ psychogenic nausea or vomiting while entering the
hospital or even at the thought of chemotherapy ward. This requires anti-anxiety drugs.
HOW TO AVOID OR TREAT VOMITING?
1. Avoid few large meals as a full stomach causes more vomiting sensation. Eat small
multiple meals instead.
2. Avoid drinking water with the meal……drink before.
3. Avoid very sweet, sour, spicy foods or foods with a strong pungent odour as these
stimulate vomiting.
4. Stay away from very fatty foods as these take longer to digest, and stay longer in stomach
bag, increasing chances of vomiting. For the same reason, chew food well.
5. Hot food has stronger odours and flavours…….so let food come to room temperature
before eating.
6. Avoid strong odours. Ladies should avoid kitchen if odours are stimulating nausea.
7. Meditation and deep breathing, walking out in fresh air, some form of distraction like
going out, watching Television, etc., may reduce vomiting.
8. Avoiding a heavy meal on the day of chemotherapy makes sense.
9. Attempt to frequently drink 100ml-200ml of various types of liquids to prevent
dehydration. But avoid soft drinks with fizz (coca cola stuff).
WHEN TO CALL YOUR TREATING MEDICAL ONCOLOGY TEAM?
When vomiting is continuous, and even tablets are coming out.
When you feel weak, or giddy, look dehydrated (signs of dehydration include sunken eyes, dark
small volume urine, low blood pressure, dry tongue, thirst. You can pinch the skin below the collar
bone and if it retracts slowly it suggests dehydration).
HAIR LOSS (ALOPECIA)
Some facts about chemotherapy induced hair loss……….
1. Not all drugs cause hair loss. In fact, most new drugs don’t.
2. Hair loss usually starts after 3-4 weeks, not immediately. It may not be total, but only a
partial hair loss, at times not noticeable.
3. Hair fall occurs because chemotherapeutic medication affects rapidly multiplying cells of the
hair root. Some inflammation of scalp may occur, leading to scalp tenderness during hair fall.
4. Hair regrows once all chemotherapy cycles are over but may be curly, and of different
colour.
WHAT CAN YOU DO FOR THIS HAIR LOSS?
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Avoid hard combs. Use soft hair brushes.
Use mild shampoos.
Avoid hot hair dryers and hair dyes.
You can use a hat, cap, scarf.
A wig matching your existing hairstyle may be ordered at the first cycle of chemotherapy. It
will be ready by the time hair fall begins. We can help you with the wig vendors. Prefer
artificial hair wigs as real hair wigs are expensive and will be useless once your hair regrows.
6. Once hair fall begins and hair starts coming off in big scary clumps, be bold and get your
head completely shaved in one go as these falling hair cause aesthetic problems and can
even clog the drains.
CHEMOTHERAPY INDUCED DIARRHOEA
It occurs because chemotherapy kills rapidly multiplying cells lining the surface of the intestine,
giving rise to small ulcers, and possible gut invasion by intestinal bacteria.
Diarrhoea may be defined as 3 or more loose stools/day above the baseline stool frequency of the
patient. Or maybe 2 loose stools within 4 hours.
WHAT CAN YOU DO TO MINIMIZE OR CONTROL THIS DIARRHOEA?
1. Avoid gut stimulants like tea, coffee, alcohol, very spicy foods, laxatives.
2. Avoid high fibre foods (raw vegetables, seeds, whole grain bread, beans, nuts) as undigested
fibre increases bowel activity, aggravating diarrhoea. But please do not make this a habit.
Fibre is good for health and is anti-cancer. All these suggestions listed are to be practiced
only briefly till diarrhoea subsides.
3. Prefer low fibre foods such as white bread, biscuits, idli, noodles, fruits without peel and
seeds, cheese, eggs, potatoes, fish.
4. Avoid oily, fried foods, ghee, as these take much longer to digest causing diarrhoea.
5. Avoid milk and milk products since chemotherapy mucositis causes lactose intolerance,
though you may try curds and butter milk.
6. Eat small frequent meals rather than heavy meals.
7. Drink plenty of fluids to avoid dehydration when you are having diarrhoea………..coconut
water, apple juice, butter milk or lassi, soups, dal. Avoid carbonated drinks (appy, coke etc.),
or let the glass stand on table and lose its fizz before drinking. Avoid hot drinks.
8. Dissolve and drink ORS powder, 1 glass after each stool.
WHEN TO CALL YOUR DOCTOR FOR THE DIARRHOEA?
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Diarrhoea is associated with stomach pain or cramps, mucus or blood in stools.
Diarrhoea continues for 24 hours, especially if 7-8 loose stools were passed.
Fever or severe mouth ulcers accompany the diarrhoea.
You are vomiting out the rehydrating fluids.
The medical oncology team may need to admit you in the daycare or the ward for infusing
intravenous fluids. Please do not try over the counter anti-diarrhoeal medicines! It can be
dangerous.
MOST IMPORTANT! CHEMOTHERAPY CAN DROP THE BLOOD COUNTS
This is the most dreaded toxicity of anti-cancer drugs. Drop in Red Blood Cells (RBC, transport
oxygen), White Blood Cells (WBC, fight infections), or platelets (stop or prevent bleeding), is often
unavoidable since these cells are produced in billions everyday by rapidly dividing stem cells in the
bone marrow. And the fast multiplying cells are the ones killed by most chemotherapy drugs.
ANAEMIA(low Haemoglobin due to low RBC count) causes fatigue, giddiness or breathlessness
especially on climbing a staircase. Anaemia usually develops after several chemotherapy cycles. It is
identified by pallor, or on CBP test. If severe (e.g. Hb< 7.5gm/dl), you may be offered a blood
transfusion prior to administering the next cycle. For milder degree of anaemia, patient should take
rest and avoid strenuous exercise or activity.
In some cases, erythropoietin injections may be used to prevent or treat anaemias.
NEUTROPENIA OR LEUCOPENIA
This means low neutrophil (ANCabsolute neutrophil count) or low WBC counts. This can occur in any
cycle of chemotherapy especially the first one. Once ANC drops below 500/cumm, you may get an
infection manifesting as……
1. Fever> 100.4°F
2. chills
3. body ache, severe weakness
4. Multiple mouth ulcers
5. infective diarrhoea or pain in abdomen
6. Painful, red and tender spots/areas in the body
7. Sore throat, cough, breathlessness, chest pain
8. Severe burning pain while passing urine or stools
9. Pain around catheter site
These are signs of dangerous infections which the recipient of chemotherapy cannot fight back due
to neutropenia and must be attended to by your medical oncologist immediately, especially if
occurring a week to 10 days after the chemotherapy cycle, the period of lowest WBC counts.
Do not use paracetamol, or antibiotics yourself.
HOW CAN YOU PREVENT INFECTIONS BETWEEN THE CHEMOTHERAPY CYCLES?
1. Practice common hygiene, especially hand washing before eating and after using toilets. (I
shouldn’t be telling you all this!)
2. Avoid crowded areas. The usual green cloth face mask often advised may not protect much
against infected or polluted air entering from sides. It should ideally be worn by the person
having cough or sneeze!
3. Avoid people who have cold, cough, diarrhoea, children with rash. These are communicable
diseases.
4. Avoid live vaccines, and stay away from recipients of live vaccines for around a week. Your
low immunity can allow the attenuated vaccine viruses to attack you.
5. Avoid constipation and quickly treat it as hard stools can cause anal fissures which may get
infected causing anal pain and fever during neutropenia.
6. Be careful while cutting nails, using knives, needles, and while gardening. Small wounds can
become infected badly.
7. Prefer electric shavers and soft tooth brushes.
8. Avoid dental procedures or minorsurgical procedures without letting the other speciality
doctor speak to your treating oncologist first. Avoiding tattooing, ear or nose piercing makes
sense.
9. Take bath daily. Use moisturising lotions if skin becomes dry and cracked.
10. Try to use gloves when gardening, handling animals, cleaning up, etc..
11. Drink reverse osmosis (RO) purified water. Wash vegetables and fruits very well before
consuming. Avoid roadside unhygienic eateries.
THROMBOCYTOPENIA OR LOW PLATELETS
This occurs mainly while treating leukaemias and lymphomas with intensive chemotherapy.
Report any kind of bleeding to the doctor, such as bleeding from nose, gums, vagina (if not part of a
normal menstrual cycle), blood in stools, red spots under skin. Also watch for sudden changes in
vision or severe headaches.
PRECAUTIONS TO AVOID BLEEDING DURING PERIOD OF LOW PLATELET COUNTS (<30,000/CUMM)
1. Avoid injuries, falls, cuts.
2. Avoid contact sports (karate, judo, kabaddi, wrestling, boxing, rugby) and other sports
(hockey, cricket, bicycle racing) that put you at a high risk of injuries, including internal
haemorrhages (bleeding in brain, abdomen, etc.).
3. Drive safely (slowly, with seat belt, helmets).
4. Avoid drugs which affect platelet count or function especially NSAIDS (pain killers).
5. Avoid alcohol.
6. Avoid straining (blowing nose hard, coughing vigorously, lifting heavy weights, bending
down or suddenly getting up, straining due to hard stools), as small bleeds can occur within
brain or eyes.
7. Prefer electric razors, soft tooth brushes.
8. Avoid vigorous/rough sexual activity. Use lubricants.