During Treatment: Dealing With Side Effects

Treatment for cancer may include many options. Surgery, chemotherapy, hormone therapy, newer biologic or targeted therapies, radiation therapy or any combination of these can bring side effects that may be mild or severe depending on the treatment and individual reactions. In the past, suffering from treatment side effects was an accepted part of cancer, but today there are many ways to ease or even prevent most of them.

Nausea and Vomiting

Treatment-related nausea and vomiting can develop at any time during treatment. The body releases a chemical called serotonin in response to several types of chemotherapy. When serotonin binds to certain receptors in the brain, patients can experience nausea. Many anti-nausea drugs (antiemetics) work by blocking and shutting down these serotonin receptors.

Chemotherapy can also cause nausea and vomiting by stimulating NK-1 receptors in the brain. NK-1 receptor inhibitors help prevent acute and delayed nausea and vomiting.

Steroids are also used to prevent nausea. Side effects can include jitteriness, but the doses used typically do not cause the effects of long-term steroid-use, such as swelling and immune suppression.

Because chemotherapy kills rapidly dividing cells, it can affect hair follicles, resulting in hair loss. The degree, pattern and timing of hair loss vary among patients, as do changes that occur during hair regrowth. Some drugs, particularly certain chemotherapies, may cause profound hair loss, whereas targeted agents that are aimed directly at cancer cells usually don’t cause any. Patients should ask their doctor about what degree of hair loss to expect with treatment.

It’s normal for patients to feel distressed about losing their hair, which usually begins around two weeks after their first treatment. The scalp may become sensitive to washing, combing or brushing during the time when the hair is falling out. Facial hair, such as nasal hair, eyelashes and eyebrows, can also fall out, as well as hair on the arms, legs and pubic area.

[Read more from CURE's annual Cancer Resource Guide for the Newly Diagnosed]

Hair Loss

Patients who experience hair loss should do whatever feels comfortable, whether it’s wearing scarves, caps, hairpieces or wigs, or simply leaving the head bare. If they think they might wear a wig or a hairpiece, patients should buy it before treatment or at the start of treatment, so the wig shop can match their hair color and texture. Many cities now have professional stylists who will cut a wig or hairpiece to a patient’s preference.

Patients should ask their doctors for a prescription for the wig because it may be covered by their health insurance. Hair should begin to grow back a few weeks after treatment ends.

Neuropathy

Patients taking mitotic inhibitors, such as taxanes and vinca alkaloids, platinum-containing agents or proteasome inhibitors may develop neuropathy in the hands and feet. It can develop weeks, months or years after treatment and typically involves the fingers and toes, or the entire hand and foot. Symptoms usually resolve completely, although it can take a few weeks to many months or even a couple of years as the nerves slowly heal. Some drugs can cause permanent neuropathy, and in rare cases, can also injure the auditory nerves, causing hearing loss.

Sensory neuropathy, the more common type, may cause pain, numbness, tingling or loss of sensation because it affects the nerves needed for touch, temperature and pain. Motor neuropathy results in a disruption of signals to the muscles and can result in symptoms, such as muscle weakness, clumsiness, balance problems and foot drop.

Patients who develop neuropathy during chemotherapy should tell their doctor right away, since more severe symptoms tend to improve slowly or persist. Neuropathy is often treated with either anticonvulsants or antidepressants because of their effects on certain chemical signals. Doctors typically prescribe a low dose and then increase as needed. A compounding pharmacy can prepare a topical cream that can reduce the severity of side effects. Also available topically is an anesthetic patch, which can be applied to intact skin in the area with the most pain. In some cases, a change in the dose or type of anti-cancer drug may be necessary.

Pain

Management strategies are available for patients who experience cancer-related pain during and after treatment. Many cancer centers have pain specialists and palliative care departments. With the help of a doctor or pain specialist, patients can develop a personal pain management plan that may include relief strategies for long-term (chronic) and short-term (acute) pain, as well as brief, severe flare-ups called breakthrough pain.

Patients who experience chronic pain may need around-the-clock medication to stay on top of the pain—this means taking drugs to prevent pain rather than waiting to relieve it once it occurs. Long-acting medications continuously given or metabolized slowly in the body are best for chronic pain and can be combined with short-acting medication for acute and breakthrough pain.

Although morphine, one of the most commonly prescribed opioids, has side effects that can include drowsiness, itching, urinary retention and nausea, it continues to be the standard for chronic pain relief. Medications are also available to relieve symptoms caused by opioids. Constipation is a common side effect of opioids; stool softeners and laxatives should be taken regularly and should be started right away. It may take time to reach a balance of pain relief and manageable side effects by gradually adjusting doses or trying different opioids. Many side effects improve once the body adjusts to the medication.

Pain relief patches that are applied to the skin for continuous release of pain medication over several days may be more convenient than oral medication, especially if patients have trouble swallowing. For chronic pain, narcotic patches can deliver opioids continuously through the skin for up to 72 hours. Newer versions of the pain patch include a potent semisynthetic opioid that has milder side effects. Narcotics are also used for breakthrough pain and come in various formulations: as a lozenge, an effervescent tablet that is held between the cheek and gum, a mouth spray, a nasal spray and a dissolvable film placed on the inner cheek. For some less-common situations, pain specialists may use nerve blocks or drugs delivered to the spinal fluid.

Patients who are worried about becoming addicted or have other concerns about taking pain medication should talk to their doctors or a pain specialist. While the fear of addiction is common, very few patients become addicted to pain medication when it is taken properly. If patients have trouble getting the pain control they need, they should work with their treatment team to get relief that works. In complicated cases where pain control is difficult to achieve, a pain specialist may be needed.

Anemia

Patients whose level of red blood cells (RBCs) drops significantly may develop fatigue, shortness of breath, heart palpitations and disorientation—all symptoms of anemia. RBCs are made from stem cells in the bone marrow and carry oxygen to the body’s tissues. Certain cancers, such as leukemia, lymphoma and myeloma, crowd out or suppress the production of healthy RBCs. Chemotherapy and radiation can damage RBCs and the stem cells that make them.

Low levels of RBCs or low hemoglobin levels—a measure of the ability of RBCs to carry oxygen—can be treated with genetically engineered erythro-poietin (EPO), a protein produced normally in the kidneys. Certain drugs that act like natural EPO lower the need for a transfusion, but patients may still need one if their RBCs dip dangerously low.

Because of serious side effects, the Food and Drug Administration does not recommend these drugs for treating anemia in patients who are not receiving chemotherapy or for patients receiving chemotherapy as a curative treatment. It’s also recommended that they only be used with a goal of avoiding transfusions or severe anemia instead of trying to get RBCs to a normal level.

Neutropenia

Neutropenia, a shortage of the white blood cells called neutrophils, can make patients prone to infection that can be indicated by fever, fatigue and body aches. Fast-growing neutrophils are quickly killed off by chemotherapy and radiation. Neutropenia can result in delayed treatment and dose reduction. Drugs that stimulate granulocyte colony-stimulating factors (particles in the body that signal white blood cells to grow) are effective at reducing neutropenia, but they may produce a side effect of bone pain.

Patients who develop neutropenia may be advised to take special precautions to prevent infection until their white blood cell count improves. Precautions include frequent hand washing, avoiding people who are sick and not eating raw fruits and vegetables. Patients who develop fever or signs of infection during their course of chemotherapy should notify their doctor immediately.

Fatigue

Approximately 90 percent of patients experience fatigue at some point during treatment. The fatigue can be mild or severe, and how it affects individuals varies greatly. Fatigue caused by anemia and low thyroid function can be treated with medication. When those causes are ruled out, the patient’s medical team will look for other approaches.

Fatigue can be worse if patients have pain, are emotionally distressed or have sleep problems. Exercise, such as walking, has been found to improve fatigue. Stimulant drugs may also be used to treat fatigue.

Other Side Effects

All patients undergoing treatment are unique—as are the side effects they experience. In addition to the ones explained here, other possible side effects include rash, cognitive dysfunction (also called chemobrain), oral mucositis (mouth sores), diarrhea, insomnia and thrombocytopenia (low platelet counts).

Patients should talk to their doctor about any side effects that they believe are associated with their treatment—both physical and psychological. There may be solutions. Also, they should ask for a name and phone number of a person to contact after hours should they experience these side effects.