Chemotherapy is an important tool in the treatment of cancer. It is used in several ways, either as Adjuvant treatment – in this case, the drugs are administered, after a primary treatment which may be surgery or radiotherapy, in order to destroy cancer cells that may have spread to different parts of the body. Therapeutic use is indicated where there is obvious spread and the drugs are being used as the primary treatment. Neoadjuvant treatment is when the chemotherapy is used for adjuvant reasons but the drugs are administered before the “primary” treatments.
Useful as chemotherapy is, the treatment may be associated with side-effects. Some of these side-effects are inevitable but others are not. The side effects may require active treatment or necessitate temporary or permanent discontinuation of therapy. It is not every patient undergoing chemotherapy that suffers side-effects; certainly many patients have an events-free chemotherapy treatment. Yet, these side-effects occur often enough in a significant number of patients to merit the attention of all.
This booklet consists of two parts. One part contains the common side effects of chemotherapy and how to cope with them, while the second part presents the National Cancer Institute of the United State of America (NCI) common toxicity criteria (CTC) in a tabular form. The methods of coping are to be used only during the duration of treatment and they are not meant to be life long. They have no direct effect on the disease process.
The information contained in this booklet has been obtained from several sources, including patients. If you learn of any method of coping with cancer chemotherapy that is not mentioned here, please let us know so that we may share it with other patients for their benefit. It is our hope that you will find within these pages a few helpful hints that will make you tolerate your treatment better.
Professor Clement A. Adebamowo
Division of Oncology, Department of Surgery,
University College Hospital, Ibadan, Oyo State, Nigeria
Office Telephone/Fax No: (234) 02-2410995,
Your usual eating habits may be altered by the chemotherapy you receive. Nausea (a feeling of wanting to vomit), anorexia (loss of appetite), vomiting, and mouth sores may affect your ability or desire to eat.
The extent of nausea and vomiting experienced varies with the drug used and your individual reaction. Some patients experience anticipatory nausea and vomiting. This occurs in patients who have been receiving chemotherapy. In this case, nausea and vomiting occurs before they receive the drugs, and it may be triggered off by a particular smell, sight or sound that is associated with chemotherapy.
Many medications are available for the treatment of nausea and vomiting. The specific type used will depend on the type of chemotherapy that you are receiving, cost considerations and your response. These drugs are generally given before you receive chemotherapy and continue for a few days after. Some anti-emetic medications can cause drowsiness; ask your oncologist, nurse or pharmacist if you should drive or operate heavy equipment.
Most anti-emetics are better started before chemotherapy is administered. Ask your doctor about this. Take the anti-emetic on a regular basis as prescribed. Do not wait for the nausea to get worse, as it may progress to vomiting.
Eat small quantities of food frequently throughout the day. Aim to eat as well as you used to in order to have energy and enhance your tolerance of treatment
Eat slowly and chew your food well.
Avoid spicy, fatty, very sweet foods, and foods with strong odors.
Eat bland foods like Garri, Bread, and Yams.
Eat foods that are cold or at room temperature. Odors from hot food may make nausea worse.
Eat light foods on the day(s) you receive chemotherapy.
After eating, relax in a sitting or slightly reclined position in a quiet area. Do NOT lie down.
Fresh air, breeze from a fan or an air-conditioner may be helpful.
Listen to music, or the radio, or watch television or read to take your mind off the nausea.
Avoid strong odours and perfumes
Do not provoke vomiting by irritating the back of your throat
It is important to make sure that you do not loose too much fluid from your body (dehydration). Try to drink about 1 glass of fluid every hour of the day.
Drink clear fluids such as water, soft drinks, and tea.
Suck ice chips to increase your fluid intake.
As your vomiting decreases, gradually start solid foods.
Inform your doctor as soon as possible that you are vomiting so that he/she can tell if and when you need additional treatment.
The lining of the mouth and digestive tract is sensitive to chemotherapy. Mouth sores and/or ulcers (blisters) caused by chemotherapy are called stomatitis. Stomatitis usually develops several days after chemotherapy. If you develop any mouth sores, you should inform your doctor or nurse. Medication is available to relieve the pain and to treat any infection in your mouth.
Soreness in the throat that is causing difficulty with swallowing is a serious side-effect of treatment which must be promptly reported to your doctor. It may signal excessively low levels of white blood cells (WBC) that help to fight infection. Several drugs are available to reverse this. Antibiotics and blood transfusions may also be required.
Eat soft foods such as eggs, mashed vegetables, rice, and noodles.
Increase your intake of beverages.
Drink juices that are low in acids.
Chew your food well to make swallowing easier.
Use a very soft bristled tooth brush or a baby tooth brush. Avoid chewing-stick
hard or crunchy foods such as popcorn, roasted corn, and roasted groundnuts.
very hot or very cold foods.
acidic, spicy and salty foods.
cigarettes and alcohol.
Eat moist foods like ice-cream.
Drink plenty of fluids.
Dip dry, crispy foods in coffee, tea, beverages, water or milk.
Avoid commercial mouthwash lotions since they can cause further mouth dryness.
Keep your lips moist with lanolin cream or lotion.
Do your oral hygiene more than once a day.
Some chemotherapy can cause a gradual thinning of hair while others can cause a complete loss of hair within 2 to 3 weeks of treatment. Hair loss is called Alopecia. The amount of hair you loose depends on the type and amount of drug(s) you receive. All other body hair, such as eyelashes, beard, and eyebrows may also be lost. Hair re-growth may begin during treatment; however it usually begins 3-4 months after treatment ends. You may notice a change in the color and texture of your “new hair”. Hair loss during treatment may be reduced by scalp tourniquet or scalp cooling. Ask your Oncologist if this is appropriate for you.
Avoid things that increase stress on your hair such as braiding, plaiting, dryers, curling irons, electric curlers, hair dyes, bleaches, permanent waves, tight elastics, hair clips and excessive brushing.
Use a wide toothed comb.
Choose a shorter hair style like “low-cut” during chemotherapy
Experiment with wigs, toupees, scarves, hats, caps and turbans for variety.
Protect from the sun those parts of the body that have had hair loss.
Use an unscented moisturizing cream to prevent your scalp and skin from drying.
The bone marrow (the soft part inside bones) makes all types of blood cells. The major types of blood cells are red blood cells, white blood cells, and platelets. Chemotherapy may decrease the number of blood cells produced by the bone marrow.
The test to measure the number of cells is known as a FBC (full blood count). You will require it before and between treatments. Your blood test can be arranged either at hospitals, clinics or community labs. However this test should be done as near the time that you will take your chemotherapy as possible. If your blood counts are too low, your treatment may be delayed or you may require transfusion of red cells and/or platelets, and or the use of growth factors. Growth factors are a new category of drugs that are similar to the proteins that regulate growth and development in the body.
Red blood cells (RBC) carry oxygen to the different parts of the body. A decrease in the number of RBCs is called anaemia. Notify your doctor or nurse if you experience:
Tiredness, weakness, or dizziness.
Shortness of breath with activity.
Ringing in your ears.
Swollen ankles & feet.
Take a rest between periods of activity.
When you have been lying down and you want to get up, sit for a few minutes before standing up in order to decrease chances of dizziness.
Ask family and/or friends to help you with shopping, child care, housework or other duties.
Eat a balanced diet. You may wish to discuss your diet with a dietitian.
Platelets are the “sticky” cells inside the blood that prevent bleeding and initiate the process of blood clotting. If your platelet count is low you may experience easy bruising or bleeding from your mouth, nose or from minor injuries.
Notify your doctor or nurse if you experience:
Small, reddish or purple spots appear in your mouth or on the skin (arms, legs, stomach).
Blood in your urine making it cloudy, reddish or brown in color.
Blood in your stools or black stools (looking like the tar on the road surface).
Unusually heavy or prolonged menstrual periods.
Avoid bumps and situations that might produce scrapes and scratches on the skin like manual labour or playing contact sports.
Avoid strenuous exercises.
Use a soft toothbrush and do NOT floss or use hard toothpicks.
Do not have dental work or any surgery at the time that you are taking chemotherapy without talking to your Oncologist.
Use an electric razor rather than a safety (disposable) razor for shaving.
Keep your nails clean and short.
Avoid constipation and straining when you are passing stool.
Blow your nose gently through both nostrils at the same time. If your nose bleeds, apply firm pressure to the area of the nostrils below the bridge of the nose and report in the emergency department.
Avoid medications that may start or prolong bleeding such as Aspirin (ASA - acetylsalicylic acid) or ASA-containing products. Anytime a drug is prescribed for you, ask to make sure that it is not likely to interact with your chemotherapy.
If bleeding occurs on any superficial part of your body, apply pressure for 10-15 minutes and go to the hospital.
Avoid drinking hot fluids or eating hot food.
White blood cells (WBC) are the cells that protect the body against infection. The number of WBCs usually decreases approximately 10 days to 2 weeks after chemotherapy is started. This is normal and your doctors ensure that it does not fall too low. When your WBC is too low, there is a higher than average risk of getting an infection.
Notify your doctor or nurse immediately if you experience:
Temperature above 38oC. Do not take any medication to lower the temperature unless your oncologist has instructed you to do so.
Chills or sweating
Burning feeling when urinating, blood in the urine, or cloudy urine.
Cough which is associated with the production of sputum.
Soreness of the mouth or throat.
Avoid crowds and people with contagious illness such as cold and catarrh, flu, cold sores, shingles, chicken pox, mumps, measles, etc. Notify your oncologist if you come in contact with any of these illnesses.
Wash your hands often during the day, especially before eating and after using the bathroom.
Keep your body clean; clean the anal area well after passing stool. It may be better to wash up with soap and water after passing stool.
Keep your teeth and mouth clean.
Protect yourself from cuts by:
wearing shoes or slippers at all times
using an electric razor instead of blade
wearing gloves for gardening, washing dishes, and during cooking.
Maintain cleanliness and lubrication during sexual intercourse.
Eat a well-balanced diet.
Avoid enemas and suppositories. Women should NOT douche or use tampons.
Avoid cleaning body wastes or animal houses in order to avoid infections
Fatigue, a feeling of tiredness or lack of energy, is a common side effect of chemotherapy. Fatigue from chemotherapy persists over time and does not go away after a good night sleep. Most people start to feel less fatigue 2-3 months after treatment is finished. Talk to your nurse, doctor or social worker about your fatigue.
Recognize that this is a side effect of your treatment and plan your activities accordingly. Do not be impatient with yourself and get frustrated
Allow for rest between periods of activity.
Identify what your priorities are.
Set realistic goals.
Ask for help.
Stay physically active and exercise regularly.
Notify your doctor so that he can manage symptoms such as pain, nausea, anaemia, and infections that make fatigue worse.
Plan activities that need thinking after you have fully rested.
Save your longest sleep for the night. Avoid catnapping that will lead to inability to sleep at night.
Try doing different things so that you do not become bored.
Avoid undue stress.
Normal bowel habits vary from person to person. Chemotherapy may affect your bowels by causing constipation or diarrhoea. It is important to keep the anal area clean to avoid infection.
Notify your doctor or nurse if you experience:
Any changes in your bowel habits such as:
Constipation or diarrhoea for more than a day
An increase of 3 to 4 bowel movements in a day over your normal
Chemotherapy and some pain medications can cause constipation.
Increase the amount of water that you drink.
Eat food that will make you pass soft stools frequently.
Increase the amount of foods such as raw vegetables, raw fruits, nuts, bran, whole-wheat etc that you eat.
Keep active - walking and exercising.
Your oncologist may recommend the use of a stool softener or laxative if symptoms persist.
If you experience diarrhoea it is important to check the colour of the stool and frequency of your bowel movements.
Decrease your intake of fibre such as raw fruits and vegetables.
Increase your fluid intake to replace fluids lost through diarrhoea.
Eat small frequent meals.
Avoid foods that can cause gas and cramping such as cabbage, onions, beans, and cauliflower.
Eat low fibre foods such as rice, amala, agidi/eko and beverages like cocoa drinks.
Eat foods high in potassium such as bananas.
Avoid milk and milk products.
Some chemotherapy can irritate the lining of the bladder, and cause a condition called cystitis. When you have cystitis, you will experience pain or burning sensation in the urinary tract on urination, a sense of sudden urge to pass urine which if not obeyed may lead to some urine being passed involuntarily, blood in the urine, and/or strong smelling urine. To reduce bladder irritation from chemotherapy, increase the amount of fluid that you drink and empty your bladder frequently.
Notify your doctor or nurse if you experience:
blood stained urine
pain or burning sensation with urination
inability to drink the required fluids.
Increase your fluid intake starting the day before your treatment, continuing the day of treatment and for 2-3 days after.
Drink 1 glass of fluid every hour when awake. Fluids include water, juice, soft drinks, broth, soup, ice cream, and ice chips.
Urinate every 2 to 3 hours when awake.
Some chemotherapy can affect the nervous system.
Notify your doctor or nurse if you experience:
unsteadiness when walking
numbness and tingling in the fingers and toes, a sensation similar to “pins & needles”.
blurred vision and light sensitivity – that is normal light looks too bright.
In most cases these side effects will disappear gradually when the drug treatment ends.
If your fingers are numb, be careful when grasping objects that are sharp or hot.
If your sense of balance is affected, move slowly and use hand rails when going up and down stairs.
Some chemotherapy drugs can cause the skin to darken and hurt when exposed to the sun. This is especially important in our part of the world where it is practically impossible to avoid the sun. The fingernails may also darken and break easily. Their growth rate may also become slower. The teeth may also change colour.
Avoid unnecessary exposure to the sun. If you have to go out use an umbrella as a sunshade.
Wear loose-fitting clothing that covers most of your body to avoid exposing them to the sun.
Wear sunglasses to protect your eyes.
Some regular body creams contain substances that reduce the amount of sun-rays that reach your skin. These creams are rated according to their concentration of Sun Protection Factor (SPF). Use one rated 15 or higher and apply it every 3 to 4 hours.
Avoid activities that may damage your nails.
Avoid amateur manicure/pedicure where your nail may be damaged and opportunity for infection created.
Use nail polish.
Chemotherapy and its effects may provoke feelings of anger, frustration, depression, worry, anxiety, and uncertainty. These are normal and form part of the human experience. It is important to keep a positive outlook and know that “while you may have cancer, cancer does not have you”.
Everybody needs support and encouragement during difficult times and you should not hesitate to ask for help from your family, friends, colleagues, other patients and care providers. You may also find great comfort in religious observances, volunteer work and in support groups. It is however most important that you demonstrate a lot of love and compassion to your own self.
Avoid self-pity and undue introspection, it is highly unlikely that you have developed cancer because of anything that you have done or that you have failed to do. Remember to occasionally “treat” yourself to a good time.
Do not let the fact that you have cancer be the defining issue in your life. You must realize that some people may not be so understanding and may reject you. In such instances, know that the problem is with them and not with you. Be realistic about your expectations of other people.
Share your experiences with others. Talk frankly about your feelings and do not try to bottle things up. Do not pretend to be happy when you are not.
Ask questions about whatever you do not understand.
Different people have different ways of coping with their problems. A self-help book or discussion with other patients may be helpful to you.
Learn how to relax. This may include listening to music or any other thing that creates pleasant experiences for you.
You may wish to keep a journal of your experience, thought and questions that crop up in your mind.
Enjoy life as much as possible.
Chemotherapy may leave you too tired to engage in sexual activities. The emotional upsets that accompany chemotherapy may also distract you and make your mind unfocussed. Some of the chemotherapy may alter your hormones in such a way that your sexual desire and interest reduces. Your feelings of attractiveness and ability to engage in sexual activities may also be affected by the physical changes that occur with treatment. On the other hand, the increased communication and closeness that the experience of illness engenders may result in the enhanced sexuality and relationships. So the response differs from one individual to the other.
Be patient with your partner. Fatigue and emotional distraction will lessen over time.
If there is vaginal dryness, a water-based lubricant like K-Y Jelly will be useful. Avoid oil based jellies.
Difficulty or pain may be due to vaginal infection which your doctor should be informed about so that you can be appropriately treated.
Do not wash/douche your vagina as you may introduce infection.
Men should wear a condom if they want to have sex within 48 hours of chemotherapy as the drugs may be excreted in the seminal fluid and may cause vaginal irritation in their partner.
Ask your Oncologist about when you can have a baby after chemotherapy.
It is advisable not to try and have a baby while you are receiving chemotherapy. Use birth control (preferably barrier methods such as condom or femdom – female condom) as chemotherapy drugs may cause birth defects if a pregnancy were to occur during treatment.
Chemotherapy may cause irregular periods and in some circumstances, cause the period to stop entirely.
Some chemotherapy may cause sterility in men. Ask your doctor if you are at risk and about sperm-banking facilities.
The side effects of chemotherapy have been categorized and their severity graded by the National Cancer Institute of the United States of America. This grading is referred to as the COMMON TOXICITY CRITERIA (CTC) and parts of the CTC are tabulated below.
Different drugs tend to cause different side effects and the severity also varies depending on dose, drug combination, your peculiar reaction, and additional therapy that you may be getting. The commonest side effects are indicated in bold print. You may wish to refer to this table often so that you can report what you are feeling accurately to your doctor.
By no means do all these side-effects occur in all patients and a lot of patients have an event-free chemotherapy treatment.
WBC = White blood cells count
PLT = Platelets
WNL = Within normal limits
Hgb = Haemoglobin
N = Normal level
PFT = Pulmonary function test
LVEF = Left ventricular ejection fraction
CHF = Congestive heart failure
ECG = Electrocardiogram