Coping With Side Effects From Cancer

Treatment for cancer could include many options. Surgery, chemotherapy, hormone therapy, biologic and targeted therapies, radiation therapy — or any combination of these — can cause side effects that range from mild to severe, depending on the treatment and individual reactions. In the past, suffering from treatment side effects was an accepted part of the cancer experience, 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. The body releases the chemical 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.

A recent study showed that nausea and vomiting are no longer the side effects that cause the most concern for patients undergoing chemotherapy, due to the effective medications that are available to prevent and treat these problems.

Patients worry more about sleep loss and the effects of their illness on loved ones, the study showed.

Hair Loss

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, can cause profound hair loss, whereas targeted agents that are aimed directly at cancer cells usually won’t cause any. Patients should ask their doctors 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 about two weeks after their first treatment. The scalp can 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.

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 thinking about wearing 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 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 might be covered by their health insurance. Hair should begin to grow back a few weeks after treatment ends.

Those who are very upset by the prospect of losing their hair, or who want to keep their illness private by preserving their usual appearance, can consider using scalp cooling caps. Also known as scalp hypothermia or cold cap therapy, this technique involves cooling the scalp for a period of time before, during and after each chemotherapy treatment. This is thought to lessen the amount of drugs reaching the hair follicles, helping to prevent or reduce hair loss. The technique seems to work best in patients whose chemotherapy regimens do not include an anthracycline, such as doxorubicin.

The DigniCap Scalp Cooling System is approved for the reduction of hair loss during chemotherapy for patients with solid tumors. The Paxman Scalp Cooling System is approved to prevent hair loss in patients with solid tumors who are undergoing chemotherapy. Both can be purchased by hospitals, which can provide them to interested patients. DigniCap includes a cap attached to an automatic cooling system. It is becoming more widely available and its cost to each patient — $1,500 to $3,000 for the duration of chemotherapy — may be at least partially covered by insurance. Those interested can ask about availability at the facilities where they receive treatment.

For approximately $450 per month, its web- site states, patients who have any kinds of solid tumors can rent Penguin Cold Caps and bring them to chemotherapy appointments. The cheapest option — a few hundred dollars — is to buy several Elasto-Gel caps online, a cooler or two and some dry ice, and have a friend come to infusion appointments to help change the caps every 30 minutes before, during and after treatment.

Some experts worry that cooling the head during treatment leaves open the possibility that cancer will spread to the scalp, but other oncologists say this is unlikely.

Patients considering scalp cooling should confer with their doctors about whether it makes sense for them.

LYMPHEDEMA

Lymphedema is swelling that can occur due to a buildup of lymph fluid, a clear liquid that moves through the body carrying proteins, water, salts and white blood cells.

Lymphedema can be caused by the removal of lymph nodes during cancer surgery, or by radiation, infection or the cancer itself. Where it occurs depends on the location of treatment. Lymphedema most often affects the arms or legs, but, alternatively, it could affect the face, abdomen, neck or genitals.

Lymphedema is treatable through techniques such as specialized massage or the use of compression garments to help keep it under control.

It’s a good idea to ask your medical team, before treatment, whether you are at risk, and what you — and they — can do to help prevent lymphedema. One method is to use presurgical or other techniques that guide doctors in removing as few crucial lymph nodes as possible.

NEUROPATHY

Patients taking mitotic inhibitors, such as taxanes and vinca alkaloids, platinum-containing agents or proteasome inhibitors, could develop neuropathy in the hands and feet. This nerve damage can develop weeks, months or years after treatment and typically involves the fingers and toes, or the entire hand and foot. Symptoms may 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, can 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 lead to muscle weakness, clumsiness, balance problems and foot drop, a condition in which the front part of the foot is difficult to lift.

Patients who develop neuropathy during chemotherapy should tell their doctors immediately. There may be things that can be done to help keep it from worsening and prevent permanent damage. Neuropathy may be treated with anticonvulsants or antidepressants because of their effects on certain chemical signals. A compounding pharmacy can prepare a topi- cal cream that might 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 might be necessary.

CANCER PAIN

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

Patients with cancer who experience pain might need around-the-clock medication to prevent the pain rather than waiting to relieve it once it occurs. Long-acting medications continuously given or metabolized slowly in the body may be best for cancer-related chronic pain and can be combined with short-acting medication for acute and breakthrough pain.

Although morphine is not used for all types of pain, and has side effects that can include constipation, drowsiness, itchiness, urinary retention and nausea, it may be the best choice for patients with cancer pain. Medications are also available to relieve symptoms caused by opioids. Because constipation is a common side effect of opioids, stool softeners and laxatives should be taken regularly. It might 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 medication over several days might be more convenient than oral medication, especially if patients have trouble swallowing. For example, narcotic patches can deliver opioids continuously through the skin for up to 72 hours. Some versions of the pain patch include a potent semisynthetic opioid that has milder side effects. Narcotics are also used for breakthrough pain and may be available 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 could 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. Although 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 teams to get relief that works. In complicated cases where pain control is difficult to achieve, a pain specialist might be needed.

There have been few studies within the United States exploring the potential medical benefits of marijuana, or cannabis. The prescription, possession or sale of the substance is legal in some states but not in others. Where cannabis is legal for medical use, each state may have its own rules about which patients are eligible.

A study whose results were published recently showed that one-quarter of patients with cancer who responded to a survey about marijuana reported using the substance to quell pain, nausea, stress or depression about their illness, or to stimulate appetite. The patients surveyed lived in a state in which medical marijuana was legal.

If you are considering using marijuana to ease side effects of your cancer or its treatments, speak confidentially with your doctor about the pros and cons, so that you can make an informed decision.

ANEMIA

Patients whose levels of red blood cells (RBCs) drop significantly can 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 the stem cells that make RBCs.

In some patients, 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. Certain drugs that act like natural EPO decrease the likelihood of a transfusion, but patients could still need one if their RBC levels 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 those receiving chemotherapy as a curative treatment. It’s also recommended that they only be used with a goal of avoiding transfusions or severe anemia, rather than to try to get RBCs to a normal level.

NEUTROPENIA

Neutropenia, a shortage of the white blood cells called neutrophils, can make patients prone to infection, which may cause 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 to allow the body to make more neutrophils. Drugs that activate granulocyte colony-stimulating factors (particles in the body that signal white blood cells to grow) are effective at reducing neutropenia, but they can produce a side effect of bone pain. Patients who develop neutropenia are advised to take special precautions to prevent infection until their white blood cell counts improve, including frequent hand washing, avoiding people who are sick and not eating raw fruits and vegetables. Patients who develop fever or display signs of infection during chemotherapy should notify their doctors immediately.

FATIGUE

Most patients experience mild to severe fatigue at some point during treatment. Fatigue caused by anemia and low thyroid function can be treated. When those causes are ruled out, the patient’s medical team will look for other approaches. Fatigue can worsen if patients have pain, are distressed or have sleep problems. Exercise, such as walking, has been found to improve fatigue.

IMMUNE-RELATED SIDE EFFECTS

Immunotherapies, particularly those known as checkpoint inhibitors, hold a lot of promise as treatments for a variety of cancers. While these drugs are generally known for being easier to tolerate than chemotherapies, they are associated with a unique array of side effects. These reactions arise from inflammation caused by the stepped-up immune system harming some normal tissue.

Immune-related side effects can include fatigue, headache, weakness, diarrhea, abdominal pain, constipation, skin rashes, itchiness, shortness of breath, cough, low blood pressure, high blood pressure, joint pain, hepatitis, inflammation of the liver, or hormonal problems such as an overactive or underactive thyroid or underactive pituitary gland.

These are most often treated with steroids, in some cases combined with temporary or permanent interruption of the immunotherapy. Imodium (loperamide) can treat milder diarrhea.

Hormonal imbalances caused by immunotherapy may end up being permanent, meaning that those affected will need to take hormone supplements indefinitely.

A more severe autoimmune reaction, which may occur in people who take CAR-T cell therapies,
is called cytokine release syndrome, and arises from the immune system attacking healthy organs while it attacks cancer cells.

This can cause side effects including serious heart and breathing problems, as well as brain issues such as confusion or the inability to understand speech.

Steroids can be used to treat cytokine release syndrome induced by CAR-T cell therapy, and approved to treat severe cases is Actemra (tocilizumab), a monoclonal antibody that suppresses the immune system.

Sometimes, immunotherapy needs to be delayed or stopped because of side effects. Patients may worry about having to stop treatment, but they should be open with their care teams about side effects as soon as they occur. This can help doctors and others on the team to control side effects before they become severe.

OTHER SIDE EFFECTS

All patients undergoing treatment are unique — as are the side effects they experience. Additional possible side effects include rash, cognitive dysfunction (also called chemo brain), mouth sores (oral mucositis), diarrhea, insomnia and low platelet counts (thrombocytopenia).

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