To my devoted readers, I apologize for the hiatus. I have been repatriating back to the USA and needed a little time to get settled again.
I have an urgent job today. On the cancer forum to which I belong is a new young lady who is preparing to start chemotherapy and wanted to know the general side effects of chemotherapy. So in the next few days I will try to cover two topics: i) general side effects and ii) a more in-depth post about the increased risk of infection during chemotherapy and how to balance life while reducing risk of fever. I will regurgitate my typical spiel that I give to my patients (although this has been awhile, since I have been living out of the country for the past year)
The side effects are not pretty or pleasant. But on those days when we feel horrible, we can gain comfort from the thought that our bad day means an even worse day for the tumor and is a step closer to being rid of cancer. When chemotherapy is effective, the side effects are temporary. Sure it is a struggle, but it is the path to returning to our normal lives and therefore well worth it! As a doctor I must have patients and parents consent to this therapy, and I know no one would ever say “yes”, except for the fact that they have a disease that requires intensive therapy and therefore in most cases the only choice is to say “yes”.
Chemotherapy or Cytotoxic Therapy, what does it mean? (When I speak about general chemotherapy, I am NOT referring to newer biological agents but mostly to drugs that have been around for years or new drugs that are closely related to these older types of medications.)
Chemotherapy is cytotoxic therapy which means medications that are toxic to cells. They kill cells because they interfere with cell division (mitosis). This occurs by interfering with genetic material (such as DNA) or the structural components of cells that help them divide (such as tubulin). In general, cytotoxic drugs do not target a specific cell but target all dividing cells. It is some of the new biological agents that target specific cells. (Since I am writing this post to explain chemotherapy to patients and NOT doctors, I will not get into the details such as the phases of cell division. But this post may still help young doctors in training think about how to approach explaining this topic to patients.) Typically, cancer cells divide at a faster rate then other cells in our body and therefore are particularly sensitive to chemotherapy. This also explains the side effects, since the general side effects occur in places in our body where cell turnover is rapid. There are certain general side effects that occur with most chemotherapy drugs, and then there are more specific side effects for particular drugs. Often these medications are used in combination. Doctors try to combine drugs with slightly different side-effect profiles so that they limit toxicity to any one organ. We also choose to use medications that work slightly differently, so that the cancer has a hard time adapting and is killed more easily.
Cytotoxic chemotherapy kills rapidly dividing cells and general side effects occur in areas of our bodies where there is frequent cell turnover:
Most chemotherapy agents cause hair loss. Some agents cause more then others, and a few agents cause very little. Most intensive chemotherapy will lead to total temporary hair loss. I cheered my hair loss as a sign that I was getting medicine that could kill my tumors. I also cheered the hiatus from shaving my legs! It is really just a cosmetic and temporary thing. There is some variation in how hair responds, and some folks will not lose all their hair even if it is the typical response of that regimen. Conversely some people may lose a lot of hair with regimes that typically are not associated with complete hair loss. Timing of hair loss also differs but typically occurs about 2-3 weeks after the first chemotherapy. Hair tends to come out in clumps and can be messy and itchy, so once it begins falling out consider shaving with clippers. My nurses arranged this to happen for me. You should avoid razors because it is likely that your body has low blood cells. I found the hospital pillow really irritating on my newly bald scalp, so I would recommend bringing your own pillow once this occurs. Keep in mind that hair grows back, sometimes a different texture, often thicker. Do things to make yourself feel beautiful. I wore eye make up and had fun picking out head scarves. Others choose to wear wigs, although not common in pediatric oncology.
The entire gut lining also has a lot of dividing cells, from mouth to rectum. Therefore irritation can happens anywhere in the GI tract:
Sores can occur in the mouth. Mouth care during chemotherapy includes special mouthwashes to help prevent infection, carries, and dry mouth. Very soft tooth brushes or sponge swabs can be used for brushing. During periods of extreme low blood counts and/or sores, mouth washes may replace brushing. Mouth sores if they occur can be painful. We need to inform our doctors if we’re having pain, so that they can adequately treat with pain medicine. Pain medicine is important for both comfort and for being able to tolerate eating and drinking. I will address the importance of pain control during cancer therapy in a separate post. Mouth care is very important when there are mouth sores because they can be a source of infection. Bacteria live in our mouths and gut.
Nausea, vomiting and anorexia (decreased eating) are common side effects during chemotherapy . Luckily today doctors have lots more ways to help patients through these side effects. See previous post. ( http://chemotherapycheerleader.com/organic-vomit-improving-the-nausea-and-vomiting-of-chemotherapy/ )
Rectal sores can occur. Thankfully they are less common than mouth sores. Since our guts are where bacteria live, this can be a source of infection, so make sure your doctor knows if you’re having pain.
Young blood cells are constantly dividing in our bone marrow; therefore all of our blood counts are lowered during chemotherapy. The degree that our cells are lowered can be determined by the blood test called a complete blood count (CBC). There are 3 major types of blood cells:
Red blood cells (RBCs): These are the cells that deliver oxygen to our tissues. Symptoms that we experience when RBCs are low (anemia) include looking pale and feeling tired. The treatment for very low red blood cells is transfusion.
Platelets: These are the cells that help stop bleeding. They are the body’s first responders to a cut. Luckily, we have more platelets then we need so they have to be very low before we need treatment. Symptoms of low platelets include: i) petechiae which are very tiny red spots on the skin, ii) mouth bleeding when brushing or nose bleeds, iii) bruising, and iv) heavy menstrual periods. Hormones are sometimes used to prevent menstrual periods during chemotherapy. Treatment for very low platelets is transfusion.
White blood cell (WBCs): These include neutrophils that fight bacterial infections and lymphocytes that fight viral infections. During bone marrow transplant, both types of cells are affected, but during regular chemotherapy low neutrophils are the major problem. Unfortunately, unlike platelets and red blood cells, these cannot easily be replaced through transfusions. (In rare cases of severe infection they can be transfused, but because of the side effects this approach is used judiciously.) Our doctor will keep us informed of our absolute neutrophil count (ANC). It is critical to let our doctor know right away if we experience fever. Typically an immediate evaluation in the emergency room is needed. Depending on the specifics of our case, our doctor may define a fever as 100.4 F (38 C) or 101 F (38.4 C). If our white count is low and we have fever, we will be treated with antibiotics. An ANC under 500 is very low, and it is during this time that we are at the greatest risk of infection. Doctors take many different variables into consideration to determine if antibiotics are to be given as an outpatient or inpatient. Most people will get a fever at least once during chemotherapy. I did. I have some patients that see this as some type of personal failure but it is not! I will write a post on how to balance living life and reducing fever risk in the next few days and explain more about the causes of fever during chemotherapy.
After each cycle of chemotherapy, our blood counts go down and usually hit a nadir around the second week. With each subsequent cycle of chemotherapy, our bone marrow may become more sensitive. There are variations in responses. It is the time to recover blood cell counts that typically drive cycles to be scheduled at 3 to 4 week intervals. Sometimes a delayed recovery can delay a cycle. This means that your doctor will typically do blood tests before each cycle to determine if you’re ready for more. Some therapy protocols will use GSCF (Neupogen/Neulasta) to stimulate WBC recovery in order to prevent delays in therapy. There are some very intensive approaches that do not require recovery in between cycles. Sometimes chemotherapy is not given as cycles but daily or weekly. In such cases there is not as much flucuation in WBC counts. As you go through chemotherapy, you will become familiarized with the specifics of the protocol that you are on.
Yay! Chemotherapy is very toxic to tumor cells, which is why it can cure many cancers! But for some very rapidly growing cancers this can cause a problem called tumor lysis syndrome. Your doctor will let you know if you’re at risk for this. In general it is more of a risk for patients with specific types of acute leukemias and lymphomas and occurs during the first cycle when the body has a high number of tumor cells. Whereas some tumors die in an organized way, other patients will have lots of cells die at once. If this occurs then cell contents can be dumped into the blood stream. This can include lots of salts that can irritate the kidneys. Your doctor can protect your kidneys with medicines that can help get rid of these salts and also through very good hydration.
Other general side effects of cancer therapy include effects on learning and memory, typically mild. For parents of children who have received chemotherapy, you should monitor their school performance. Learning issues can be overcome with extra help and support, so let your doctor and school know if you see a change. To combat the slight changes that I have noticed in myself, I do brain or puzzle-solving exercises. Specific drugs can also cause other problems such as irritation of our kidneys, liver, heart, and nervous system. When a doctor consents for us to undergo chemotherapy, he will tell us some of the specifics effects of each drug. Based on the specific treatment regimen, doctors will determine the pre-chemotherapy testing. This may include testing heart function (ECHO), hearing, kidney function (scan, blood and/or urine collection) and liver function (blood tests). Because chemotherapy can interfere with our genetic material, some agents can increase the risk of second cancers occurring. Your doctor will let you know if you’re receiving such a medication. Luckily, these cases are very rare.
Although cancer therapy often makes us feel unwell and can causes a lot of side effects, it is temporary. If it works to destroy the tumor and returns us to a normal life, it is worth it! Chemotherapy is most effective when taken on a strict schedule, so compliance with the therapy recommendations is very important. These treatments are different from other areas of medicine where the treatments often make one feel better right away. Cancer treatments can make us feel worse while they are making us better. Luckily today there are a lot of more medications to help ease the side effects. So yes chemotherapy can suck, but when we are done hopefully we can toast to our remission.
Sending you love and strength,