The number of available systemic anti-cancer treatments has increased considerably over the past few decades, ranging from conventional cytotoxic chemotherapy agents, to targeted anticancer drugs, hormonal treatments and immunotherapy.
While considerable hype surrounds the newer classes of agents, conventional cytotoxic chemotherapy still plays an important role in the treatment of most cancer types.
Individuals undergoing chemotherapy are faced with some common side effects. While chemotherapy is an important tool in the treatment of cancer, support from caregivers and physicians can help individuals cope with the side effects. In this article, we take a closer look at some of the side effects that come with chemotherapy.
Nausea and vomiting remains the most feared side effect amongst individuals undergoing chemotherapy. While a majority of patients experience different degrees of nausea, the incidence of actual vomiting has decreased considerably, with the use of newer anti-emetic drugs. These have significantly improved a patient’s tolerance to chemotherapy.
Chemotherapy related nausea and vomiting are commonly classified into the following subtypes: acute, chronic and anticipatory.
Individuals with acute side effects of nausea and vomiting usually see its effects within one day of receiving chemotherapy, while individuals with chronic nausea and vomiting will experience it for a few days, and occasionally, up to a week or longer.
Physicians typically use a combination of anti-nausea medication to overcome this side effect, and if needed, additional medications can be prescribed for subsequent cycles. Conversely, anti-emetics might be stopped or doses reduced if the patient reacts well to the chemotherapy.
Anticipatory nausea and vomiting are typically related to anxiety. Individuals often experience nausea and some vomiting on the scheduled date of chemotherapy, upon arrival at the hospital or in the treatment room. This is typically triggered by sensory stimuli such as sounds, sights, and smells within the hospital.
Meditation, relaxation techniques and having a relative or close friend accompany individuals for chemotherapy often helps. Anti-anxiety medication may be prescribed if the nausea and vomiting is significant. Such medication is typically taken before a patient comes for their treatment.
Loss Of Appetite
Individuals may experience loss of appetite caused by the cancer itself, or by the treatments administered.
Nutritional supplements such as milk or dairy products may be needed to help the patient overcome the effects of cancer treatment and achieve adequate nutrition and hydration. Family members and caregivers can play a part to make meals more enjoyable by having regular family meals, and cooking varied foods with better nutritional values and tastes.
Chemotherapy often causes the thinning of the oral mucosae and decreased saliva production. Painful mouth ulcers can develop, which affect the patient’s ability to eat or drink.
Patients are advised to take frequent sips of fluids throughout the day to keep the mouth lubricated. Toothbrushes with soft bristles and non-alcoholic mouthwash can help improve good oral hygiene and reduce pain caused by the ulcers. Eating soft foods such as porridge, soups and stews instead of hard, fried and oily foods helps. Avoid snacking on hard solid food, drinking hot beverages or consuming spicy food as these can trigger and aggravate existing ulcers.
In the treatment of oral ulcers, oral gels and topical analgesics may be prescribed. In severe cases, a temporary feeding tube might be inserted through the nose to allow the patient to achieve adequate hydration and nutrition.
Individuals undergoing chemotherapy treatment may experience diarrhoea or constipation, depending on the prescribed chemotherapy agents, prior surgical procedures or changes in the dietary habits. For chemotherapy agents that are more likely to cause diarrhoea, physicians may preemptively prescribe antidiarrhoea agents and oral antibiotics. Individuals are advised to take these medications as instructed, and to seek medical help if diarrhoea persists.
Chemotherapy denudes the intestine lining and impairs the ability to absorb nutrients. As such, taking multiple small meals and avoiding high fibre and high fat diet food may help manage diarrhoea and abdominal pains. Individuals with low lactose tolerance are recommended to avoid milk and dairy products, and to drink plenty of fluids to stay hydrated. Admissions for intravenous hydration and nutrition, with a period of bowel rest might be needed for severe bouts of diarrhoea.
Medications such as opioid analgesics for pain and anti-nausea drugs that are used to combat nausea and vomiting often causes constipation in individuals dealing with cancer. When faced with this side effect, physicians will routinely prescribe laxatives. Individuals are advised to seek medical help if they experience severe constipation. Rectal enemas and manual rectal evacuation might be needed in serious cases.
Individuals are advised to drink plenty of fluids and include adequate fibre in their diet.
Chemotherapy is known to cause fatigue in individuals dealing with cancer. Individuals often experience a degree of tiredness after every chemotherapy treatment. As they progress through the treatment cycles, the baseline level of fatigue may increase.
Individuals are advised to avoid strenuous activities during chemotherapy. Light regular exercises and adequate rest are encouraged while caregiver support with the daily routines may help.
Bone Marrow Suppression
Chemotherapy affects the bone marrow’s ability to produce red blood cells, white blood cells and platelets. The degree and duration of this bone marrow suppression depends on the type and combination of chemotherapy used. Regular blood tests are needed to monitor the level of blood components. Physicians might opt to adjust doses of chemotherapy administered, defer chemotherapy or to switch treatments if needed. At times, individuals might be admitted for transfusions.
Most individuals who experience bone marrow suppression may encounter red blood cell deficiency also known as anaemia. Anaemia can aggravate fatigue and affect a person’s day-to-day functions, resulting in breathlessness (typically on exertion), giddiness and occasional fainting.
Individuals are not required to limit their meat intake during treatment. Iron supplements and erythropoiesis stimulating agents might be prescribed by physicians to increase red blood cell production and if severe, individuals will undergo transfusions.
Patients may also experience low platelets which affects a person’s clotting function. When experiencing low platelet count, nose or gum bleeding risk increases and individuals are easily bruised and may experience prolonged bleeding from simple cuts. Individuals are advised to avoid heavy manual work, contact sports or vigorous exercises following chemotherapy.
One of the most feared and potential complications of chemotherapy is known as febrile neutropenia. Individuals with febrile neutropenia have a severe deficit of neutrophils in the blood stream, to fight infections. Mild infections in a patient with neutropenia can become serious and life threatening in a matter of hours.
Individuals are advised to return to their hospitals or respective oncologists should they experience fever after chemotherapy. Should their neutrophil count fall below a certain threshold, admission for intravenous antibiotics might be warranted. Neutrophil stimulating factors are commonly administered to individuals following chemotherapy to reduce the likelihood of such occurrences. Post chemotherapy, individuals are advised to avoid crowded places and to stay away from close contacts who are unwell.
The loss of hair during chemotherapy can be distressing for most individuals. However, the degree of hair loss varies from each regimen and differs between individuals. Hair loss typically starts after a few treatments and not immediately. Hair loss is usually not limited to the scalp, areas such as the axillae, eyebrows and pubic region can also be affected.
Individuals are recommended to avoid harsh shampoos, vigorous combing, use of curlers and perms. As treatment commences, patients may also choose wigs or hair prostheses that closely match their hair texture and color. Support groups are useful and often conduct meetings and sessions to help cancer individuals cope with issues of treatment-related physical changes to their body.
In summary, the occurrence and severity of the different side effects mentioned above varies from patient to patient, and treatment regimen to treatment regimen. When faced with any side effects or changes in daily living, individuals are advised to alert the attending physician for further preventive medication to be prescribed. The doses of the chemotherapy can be adjusted or in situations of poor treatment tolerance, regimens might need to be changed.
Our nurse educators, pharmacists, and dietitians are available to help patients through this difficult period of their cancer treatment. In Tan Tock Seng Hospital, our various support groups meet on a regular basis, to provide respite for individuals dealing with cancer and support for individuals to face cancer survivorship with strength and confidence.
Dr Yeo Wee Lee is a Consultant of the Medical Oncology Department at Tan Tock Seng Hospital and the Johns Hopkins Singapore International Medical Centre. He graduated from the National University of Singapore and went on to receive his specialist training in medical oncology at the National University Hospital. He spent a year pursuing lung cancer research at Harvard Medical School. His sub-specialty interests are in head and neck, thoracic and gastrointestinal malignancies.