Management Strategies for Cancer Therapy Side Effects

March 9, 2012
Staff Reports

CURE, Supplement 2012, Volume 11, Issue 0

Common side effects caused by treatment can be controlled.

Treatment for cancer may include surgery, chemotherapy, hormonal therapy, newer biologic or targeted therapies, radiation therapy or any combination of these modalities. Each treatment brings with it side effects that may be mild or severe depending on the dose and individual reactions. In the past, suffering from side effects of treatment was an accepted part of the cancer journey, but today there are many ways to ease or even prevent most side effects.

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, it can result in nausea. Many anti-nausea drugs (antiemetics) work by blocking and shutting down these serotonin receptors.

Aloxi (palonosetron) prevents short-term as well as prolonged nausea. Other medications that prevent the acute nausea that occurs within the first day after therapy and are somewhat effective with long-term nausea include Anzemet (dolasetron), Kytril/Sancuso (granisetron), and Zofran (ondansetron).

Chemotherapy can also cause nausea and vomiting by stimulating NK-1 receptors in the brain. Emend, in both oral and injectable form, is an NK-1 receptor inhibitor that helps prevent acute and delayed nausea and vomiting.

Steroids, such as Decadron (dexamethasone), are also used to prevent nausea. Side effects can include jitteriness. Dosages used to prevent nausea typically do not cause the effects of long-term steroids, 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. Drugs, such as Adriamycin (doxorubicin), may cause profound hair loss, whereas targeted agents that are aimed directly at cancer cells shouldn’t cause hair loss.

It’s normal for patients to feel distressed about losing their hair, which can begin as soon as two weeks after the first treatment. The scalp may become sensitive to washing, combing or brushing during the time when hair is falling out. Facial hair, nasal hair, eyelashes and eyebrows may also fall out, as well as hair on the arms and legs, and in the pubic area. Strategies to reduce or prevent hair loss caused by cancer drugs generally do not work.

Patients who experience hair loss are encouraged to do whatever feels comfortable, whether it be wearing scarves, caps, hairpieces or wigs, or simply leaving the head bare. It may help to cut the hair short before it starts falling out. Patients who are considering buying a wig might want to do so before treatment or at the start of treatment so that the wig shop can match hair color and texture.

Patients taking certain chemotherapies, such as cisplatin, Taxol (paclitaxel), Taxotere (docetaxel), Oncovin (vincristine), Velcade (bortezomib) or Navelbine (vinorelbine), may develop neuropathy, or injury to peripheral nerves—the tiny nerves in the hands and feet. Neuropathy 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, including Oncovin and cisplatin, can cause permanent neuropathy. 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 lead to symptoms such as muscle weakness, clumsiness, balance problems and foot drop (a condition that causes the patient to drag the front of the foot when walking).

Patients who develop neuropathy during chemotherapy should tell their doctor right away, since more severe symptoms tend to recover slowly or persist. Neuropathy is often treated with either Neurontin (gabapentin) or antidepressants because of their effects on certain chemical signals. A compounding pharmacy can prepare a topical cream containing the active ingredient in Neurontin, which can reduce the severity of side effects. Also available topically is a lidocaine patch (Lidoderm), 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.

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.

Pain treatments are available to provide relief to patients who experience cancer-related pain during and after treatment. Many cancer centers now have pain specialists and palliative care departments to help with this. With 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 the brief, severe flare-ups called breakthrough pain.

Patients with chronic pain may need 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 medications 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 prior to medication. 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, which can be applied to the skin for continuous release of pain medication over several days, may be more convenient than oral medication, especially if a patient has trouble swallowing. The fentanyl patch (Duragesic), used 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 swab that can be sucked (Actiq), an effervescent tablet that is held between the cheek and gum (Fentora), and a dissolvable film that is put on the inner cheek (Onsolis). In the past year, the FDA approved two new fentanyl products: a nasal spray (Lazanda) and a tongue spray (Subsys).

Patients who are worried about becoming addicted or have other concerns about taking pain medication should talk to their doctor or a pain specialist. While fear of addiction is common, very few patients become addicted to pain medication when it is properly taken for cancer-related pain. In complicated cases when pain control is difficult to achieve, a pain specialist or team may be needed.

Patients may be prone to infection if they develop neutropenia, a shortage of the white blood cells (neutrophils). Fast-growing neutrophils are quickly killed by chemotherapy drugs and radiation therapy. Fever, fatigue and body aches may be signs of neutropenia, which can be diagnosed by a blood test.

The most common 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. While these drugs can cause bone pain, they can prevent treatment delay or chemotherapy dose reduction.

When patients develop neutropenia, their doctor or nurse may advise them to take special precautions to prevent infection until their white blood cell counts improve, such as frequent hand washing, avoiding contact with people who are sick and not eating raw fruits and vegetables. Fever or signs of infection in patients receiving chemotherapy should be reported to the doctor right away.

Cancer-related fatigue, which does not improve with sleep or rest, can be caused by anemia, low thyroid function or cancer treatments, including radiation, chemotherapy, hormonal therapy and biologic therapy. Although not everyone may experience fatigue to an intense degree, approximately 90 percent of patients are affected by cancer-related fatigue at some point during treatment. Both how and when fatigue affects an individual can vary, which makes it hard to recognize, describe and treat this symptom.

Fatigue caused by anemia and low thyroid function can be treated with medication. When those causes are ruled out, the medical team will look at other approaches to treatment. Fatigue can be worse when patients have pain, are emotionally distressed or have sleep problems. Poor nutrition and physical inactivity can also cause fatigue. Education and counseling are often part of the treatment and can help patients learn how to save energy and reduce stress.

Exercise, such as walking, has been found to improve cancer-related fatigue. Stimulants like Ritalin (methylphenidate), which is commonly used to treat attention deficit disorder, may also be helpful. Provigil (modafinil) is another stimulant that has been used to treat cancer-related fatigue.

Each person undergoing treatment is unique—as are the side effects he or she experiences. In addition to the ones explained here, other possible side effects include rash, cognitive dysfunction (also called chemobrain), oral mucositis (mouth sores), insomnia, anemia (a drop in red blood cells) and thrombocytopenia (low platelet counts), which can result in life-threatening bleeding. Patients should talk with their doctor about the side effects they can expect and about any side effects they experience during treatment.

[Read about six side effects you may not expect during cancer.]