Treatment for cancer may include many options. Surgery, chemotherapy, hormonal therapy, newer biological or targeted therapies, radiation therapy or any combination of these therapies 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 treatment, but today there are many ways to ease or even prevent most side effects.

Nausea and Vomiting

Cancer-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, you can become nauseated. Many anti-nausea drugs (antiemetics) work by blocking and shutting down these serotonin receptors.

Aloxi (palonosetron) prevents short-term as well as prolonged nausea, while other drugs are designed to prevent only the acute nausea that occurs within the first day after therapy. Anzemet (dolasetron), Kytril/Sancuso (granisetron) and Zofran (ondansetron) are given by mouth, as a skin patch or intravenously before chemotherapy.

Chemotherapy can also cause nausea and vomiting by stimulating NK-1 receptors in the brain. Emend (aprepitant), an NK-1 receptor inhibitor, helps prevent acute and delayed nausea and vomiting.

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

Hair Loss

Because chemotherapy kills rapidly dividing cells, it affects 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. Drugs, such as Adriamycin (doxorubicin), may cause profound hair loss, whereas targeted agents that are aimed directly at cancer cells shouldn’t cause any hair loss. Your doctor can tell you what degree of hair loss to expect with treatment.

It’s normal to feel distressed about losing your hair, which usually begins around two weeks after your first treatment. Your scalp may become sensitive to washing, combing or brushing during the time when your hair is falling out. Don’t be alarmed if hair on your face, such as nasal hair, eyelashes and eyebrows, also falls out, as well as hair on your arms, legs and pubic area. Strategies to reduce or prevent hair loss caused by cancer drugs generally do not work, but new adaptations of scalp cooling that are now being studied have provided some promising results.

If you experience hair loss, do whatever feels comfortable, whether it be wearing scarves, caps, hairpieces, wigs or simply leaving your head bare. It may help to cut your hair short before it starts falling out. If you think you might wear a wig, buy it before treatment or at the start of treatment so the wig shop can match your hair color and texture. Many cities now have professional stylists who will cut your wig to your preference.

Ask your doctor for a prescription for the wig because it may be covered by your health insurance. (Check with your insurance company to find out if and how this should be done.)Your hair should begin to grow back within a few weeks after treatment ends.

Neuropathy

If you are taking cisplatin, Taxol (paclitaxel), Taxotere (docetaxel), Oncovin (vincristine), Velcade (bortezomib) or Navelbine (vinorelbine), you may develop neuropathy, or injury to peripheral nerves— the tiny nerves in your hands and feet. Neuropathy can develop weeks, months or years after treatment and typically involves the fingers and toes, or possibly the entire hand and foot. Symptoms may gradually resolve as the nerves slowly heal. Some drugs, including Oncovin and cisplatin, can cause permanent neuropathy. Although rare, cisplatin 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.

If you develop neuropathy during chemotherapy, it’s important to tell your doctor right away. Neuropathy is often treated with either Neurontin (gabapentin) or antidepressants because of their effect on certain chemical signals. If your doctor prescribes Neurontin, you will probably start with a low dose, which will be increased as needed. A compounding pharmacy can prepare a topical cream containing the active ingredient in Neurontin to rub on your skin, which can reduce the severity of side effects. Also available topically is a lidocaine patch (Lidoderm), which you can apply 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

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

If you have chronic pain, you 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. Be patient with your pain plan. 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 your 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 you have trouble swallowing. The fentanyl patch (Duragesic) for chronic pain delivers opioids continuously through the skin for up to 72 hours. Newer versions of the pain patch include buprenorphine, a potent semisynthetic opioid that has milder side effects than morphine. Fentanyl is also used for breakthrough pain and comes in various formulations: a lozenge that dissolves in the mouth (Actiq), an effervescent tablet that you hold between your cheek and gum (Fentora and Abstral) and a dissolvable film placed on the inner cheek (Onsolis).

If you’re worried about becoming addicted or have other concerns about taking pain medication, talk to your doctor 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 you have trouble getting the pain control you need, don’t give up. Work with your treatment team to get relief that works for you. In complicated cases where pain control is difficult to achieve, a pain specialist may be needed.

View Illustration: Cancer Pain At Its Source

Anemia

If your level of red blood cells (RBCs) drops significantly, you 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, myeloma and lymphoma, crowd out or suppress 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 erythropoietin (EPO), a protein produced normally in the kidneys. The drug Procrit (epoetin alfa), which is identical to the body’s own EPO, tells the body to create more RBCs. Another drug, Aranesp (darbepoetin alfa), also acts like natural EPO. These drugs lower the need for transfusion, but if your RBCs dip dangerously low, you may still need a blood transfusion.

Because of serious side effects, the FDA does not recommend these drugs for treating anemic cancer 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

You may be prone to infection if you develop neutropenia, a shortage of the white blood cells called neutrophils that can be indicated by fever, fatigue and body aches. Fast-growing neutrophils are quickly killed off by chemotherapy drugs and radiation therapy. Neutropenia can result in delayed treatment and dose reduction. The most popular treatment to reduce neutropenia and risk of infection is Neupogen (filgrastim), a drug that stimulates granulocyte colony-stimulating factors, particles in the body that signal white blood cells to grow. Neulasta (pegfilgrastim) is a newer and longer-lasting version of Neupogen. A side effect of these drugs may be bone pain.

If you do develop neutropenia, your doctor or nurse may advise you to take special precautions to prevent infection until your white blood cell count improves.

Examples of these precautions include frequent hand washing, avoiding people who are sick and monitoring your diet to avoid raw fruits and vegetables. If you develop fever or signs of infection during your course of chemotherapy, notify your doctor immediately.

Fatigue

Approximately 90 percent of patients experience cancer-related 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, your medical team will look for other approaches.

Fatigue can be worse if you have pain, are emotionally distressed or have sleep problems. Exercise, such as walking, has been found to improve cancer-related fatigue. Stimulants, such as Ritalin (methylphenidate), which is commonly used to treat attention deficit disorder, may also be helpful.

Provigil (modafinil) is another stimulant drug that has been used to treat cancer-related fatigue.

Other Side Effects

Every person undergoing treatment is 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), insomnia and thrombocytopenia (low platelet counts), which can result in life-threatening bleeding.

Talk to your doctor about any side effects that you believe are associated with your treatment— both physical and psychological. There may be solutions.

 

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