Managing side effects of chemotherapy

Friday 1 August, 2014

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On this page: Feeling tired and lacking energy | Appetite changes, nausea and vomiting | Hair loss | Skin and nail changesMouth sores | Memory and concentration changes | Effects on the blood and immune system | Change in hearing | Constipation and diarrhoeaSex and fertility | Nerve and muscle effects 


While chemotherapy can kill cancer cells, it can also affect normal cells that grow or divide rapidly, such as those in the bone marrow, digestive tract, skin, hair and reproductive organs. When the normal cells are damaged, this causes side effects.

This section discusses the most common side effects people experience and offers suggestions to help manage them. Whether or not you experience side effects, and how severe they are, depends on the type and dose of drugs you’ve been prescribed and how you react individually from one treatment cycle to the next.

Side effects vary greatly. Some people will have no side effects, others will experience a range. If you have side effects, they will usually start during the first few weeks of treatment, however they can accumulate with each cycle.

Most side effects are temporary and can be managed. They tend to gradually disappear once treatment has stopped and your normal healthy cells have recovered. Depending on the side effects you experience, your doctor may change the dose or type of chemotherapy.

You should talk to your doctor or nurse before your treatment begins about the side effects you should watch out for or report, and who to contact out of hours if you have immediate concerns.

If the side effects change your appearance and self-esteem, consider attending our free Look Good...Feel Better workshops.

Chemotherapy diary

It can be useful to record information about your chemotherapy treatment in one place so you recall details about when you experienced side effects, how long they lasted and what helped to reduce them. Some people use a notebook or a diary (download a PDF of our Chemotherapy booklet for a blank diary you can fill in and photocopy), while others prefer technology such as a smartphone. You may want to make a note of the date, time, symptoms experienced.

Sharing the information you record with your doctors and nurses will help them give you suggestions for dealing with side effects or adjust your treatment, if appropriate.

Feeling tired and lacking energy

Feeling tired and lacking energy (fatigue) is the most common and often, debilitating side effect of chemotherapy. Fatigue can include feeling exhausted, drowsy, confused or impatient. You may have a heavy feeling in your limbs, or find it difficult to do daily activities.

Fatigue can appear suddenly and rest may not relieve it. You might still feel tired for weeks or months after a treatment cycle ends.

"I had no idea that I would still be feeling tired five months after finishing treatment... I didn't know how to make it better and I was scared that's how it would be: that I wouldn't go back to normal, that I would never go back to having energy again." - George, bowel cancer

Tips

  • Save your energy. Help your body recover by doing only the things you really need to do and resting more.
  • Let people help you. Family, friends and neighbours often want to assist but may feel unsure about what to do. They could help with shopping, driving, housework or gardening.
  • If you have children, ask for help looking after them during chemotherapy and a few days afterwards.
  • Plan activities for the time of day when you tend to feel most energetic.
  • Do light exercise, such as walking, and/or keep up with your normal exercise routine. Regular exercise can help reduce fatigue and increase appetite. Talk to your health care team about suitable activities for you.
  • Try to eat a well-balanced diet with plenty of fruits and vegetables.
  • Do relaxation or meditation exercises to see if they improve your sleep or give you more energy. Order a free copy of Cancer Council’s Relaxation CD and Meditation CDs.
  • If you have a poor appetite, nausea or vomiting, see below for tips.
  • Check with your doctor whether your fatigue is related to low red blood cells (anaemia) so that this can be treated – see below.
  • Discuss the impact of your treatment with your employer. Some workplaces may allow you to work flexibly during or after chemotherapy. Options include taking a few weeks off work, reducing your hours or working from home.

Appetite changes, nausea or vomiting 

It is common for your appetite to change when you are going through chemotherapy, and some drugs temporarily change the taste of foods. Sometimes you may not feel hungry, or you may not enjoy the foods you used to like or crave foods you don’t usually eat.

Chemotherapy can make you feel sick (nauseated) or cause you to vomit. Your medical oncologist will tell you if the drugs you are given are likely to cause nausea and vomiting. Not everyone feels sick during or after chemotherapy but, if nausea affects you, it usually starts a few hours after treatment. Nausea may last for many hours and be accompanied by vomiting or retching. Sometimes nausea lasts for days after treatment.

Anti-nausea (anti-emetic) medication helps most people avoid chemotherapy related nausea or vomiting. This medicine can be taken before, during or after treatment. It may be available as::

  • injections: usually given before chemotherapy
  • tablets: can be taken regularly at home
  • liquids: added to the chemotherapy
  • wafers: dissolved under or on top of the tongue
  • suppositories: placed in the rectum where they dissolve.

Finding a combination of anti-nausea medication that works for you can take time. If you still have nausea or vomiting after using the prescribed medication, let your nurse or doctor know.

Being unable to keep liquids down because of vomiting can cause you to become dehydrated.

Tips

  • If you are nauseous or have vomited a lot, try to keep your fluids up so that you don’t get dehydrated. If you aren’t able to keep fluids down, contact your doctor immediately.
  • Eat a light meal before your treatment (e.g. soup and dry biscuits or toast), and drink as much fluid as possible.
  • Sip fluids throughout the day, rather than trying to drink a lot at once. Sucking on ice cubes, ice-blocks or jellies can also help to increase your fluid intake.
  • If your stomach is upset, try drinking fizzy drinks such as soda water or dry ginger ale.
  • If you wake up feeling sick, eat a dry biscuit or a slice of toast rather than skipping food altogether or forcing yourself to have a full meal.
  • Breathe deeply and gently through your mouth if you feel like you’re going to vomit.
  • Avoid strong odours and cooking smells.
  • Eat and drink slowly. Chew your food well to make it easier to digest.
  • Prepare meals between treatments and freeze them for the days you don’t feel like cooking.
  • Eat what you feel like, when you feel like it. For example, have cereal at dinner time and a main meal at lunch.
  • Have small, frequent snacks instead of large meals.
  • If the taste of certain types of food has changed, don’t force yourself to eat them. Your sense of taste should return to normal after treatment ends, but it may take some time.
  • Ask your treatment team about taking a stool softener if the drugs make you constipated.
  • Speak to the hospital dietitian for advice about eating..

Call Cancer Council 13 11 20 for free information about eating healthily during and after treatment.

Hair loss

Many people having chemotherapy worry about hair loss. Some people lose all their hair quickly, others lose it after several treatments, or others may only lose a little hair or none at all.

Whether or not you lose your hair depends on the drugs you receive. Some drugs don’t cause this side effect. Ask your doctor if hair loss is a possibility and how you can prepare. 

When hair loss does occur, it usually starts 2–3 weeks after the first treatment and grows back when chemotherapy is completed. Before, and while your hair is falling out, your scalp may feel hot, itchy, tender or tingly. Some people find that the skin on their head is extra sensitive, and they may develop pimples on their scalp.

Although losing head hair is most common, you may also lose hair from your eyebrows, eyelashes, arms, legs, chest and pubic region.

It takes 4–12 months to grow back a full head of hair. When your hair first grows back, it may be a different colour or curly (even if you have always had straight hair). In time your hair usually returns to its normal condition.

Many people find losing their hair very difficult. You may feel that your hair is part of your overall image and its loss can make you feel physically unattractive, vulnerable or sad. It’s natural to feel this way. Talking to your medical team may be helpful.

Tips

  • Keep your hair and scalp very clean.
  • Use a mild shampoo like baby shampoo. If you want to use lotion on your head, use sorbolene. Check with your nurse before using any other hair or skin care products.
  • Comb or brush your hair gently using a large comb or hairbrush with soft bristles.
  • Cut your hair, especially if long, before it falls out. This can be less upsetting.
  • Wear a light cotton turban or beanie to bed if you are cold at night, or to collect hair.
  • Use a cotton, polyester or satin pillowcase, as nylon can irritate your scalp. If you prefer to leave your head bare, protect it against sunburn and the cold.
  • Limit the use of hair dryers, rollers and harsh products.
  • Talk to your hairdresser about making your hair look as good as possible even if it is thin or patchy. If you want to dye your hair, use vegetable- based dyes or those low in chemicals. Test a small area of hair for a reaction before colouring your whole head.
  • If your eyelashes fall out, wear glasses or sunglasses to protect your eyes from the dust and sun while outside.
  • Tell your nurse or doctor if the skin on your scalp is very sensitive, or if you have a lot of discomfort and itchiness.
  • Wear a wig, toupee, hat, scarf or turban. Do whatever feels the most comfortable and gives you the most confidence.
  • Consider choosing a wig before chemotherapy starts. You can borrow a wig from hospitals or treatment centres with a wig library. If you want to buy a wig and you have private health insurance, check with your fund if you are eligible for a rebate.

Call Cancer Council 13 11 20 for assistance in finding a wig library or shop.

Skin and nail changes

Some chemotherapy drugs can affect your skin. It can darken, peel or become dry and itchy. It is also likely to be more sensitive to the sun, during and after treatment.

Some people find their nails also change and become brittle and dry, develop ridges, or have white lines across them.

Tips

  • Use a moisturising soap or sorbolene cream as a soap replacement.
  • After showering, gently pat your skin dry with a towel. Try not to rub your skin too hard.
  • Use a moisturising lotion or cream containing the ingredient urea to stop the dryness.
  • Wear loose, non-restricting clothing. Choose cotton fabric instead of rough wool or synthetic fibres.
  • Wash your clothing in mild detergent for people with sensitive skin.
  • Stop shaving or waxing until your skin is completely healed.
  • Protect your skin from the sun – especially between 10am and 3pm – by wearing high-protection sunscreen (SPF 50+), a hat and protective clothing. This advice applies to everyone, but is especially important for people having chemotherapy.
  • If your skin becomes red or sore in the area where the intravenous device went in, tell your doctor or nurse immediately.
  • Avoid chlorinated swimming pools as the water can make skin changes worse.

Mouth sores

Some chemotherapy drugs can cause mouth sores such as ulcers or infections. This is more likely if you have had or are having radiation to the head, neck or chest, or if you have dental or gum problems. If you notice any change in your mouth or throat, such as sores, ulcers or thickened saliva, or if you find it difficult to swallow, contact your doctor. 

Tips

  • Discuss any dental problems with your doctor before seeing the dentist. If you need any dental work, tell your dentist you are having chemotherapy.
  • Use a soft toothbrush to clean your teeth twice a day.
  • Soothe tender gums and mouth sores with plain yoghurt.
  • Keep your mouth clean and use a mouthwash to help heal mouth sores. Don’t use commercial mouthwashes containing alcohol as they may dry out or irritate your mouth. Try a homemade mouthwash (1 tsp bicarbonate of soda or salt in a glass of warm water) at least four times a day. Start when treatment commences to prevent mouth ulcers occurring.
  • Sip fluids, especially water, and eat moist foods such as casseroles or soups if you have a dry mouth. Moisten foods with butter and sauces.
  • Try sucking on ice while you’re having intravenous chemotherapy to reduce mouth ulcers.
  • Blend foods to make them easier to eat.
  • Avoid very hot foods, and spicy, acidic or coarse foods, (e.g. nuts or grains), as these can aggravate mouth sores.
  • Don’t smoke or drink alcohol, as this irritates the mouth.

Memory and concentration changes

Some people say they have trouble thinking clearly following chemotherapy. This is called cognitive impairment or, sometimes, ‘chemo brain’. You may find that it takes you more time to process information, or you may experience short-term memory loss or have trouble concentrating for long periods.

There is some evidence that self-help techniques such as relaxation, exercise and memory games can help. Tell your doctor if this issue is affecting your day-to-day life.

Tips

  • Use a calendar to keep track of tasks, appointments, social commitments, birthdays, etc.
  • Write down what you have to remember. For example, make to-do lists or record where you parked the car.
  • Choose activities that require less concentration. For example, read magazines with short articles instead of books with several characters or complex storylines.
  • Learn something new, take up a new hobby, or do crosswords or number puzzles.
  • Plan activities so you do things that require more concentration when you are fresher, such as in the morning.
  • Get plenty of sleep. Deep sleep is important for memory and concentration.
  • Do light exercise each day. This may help you to clear your mind and sleep better.
  • Talk to your partner, family or friends about how you’re feeling. This can help prevent misunderstandings and frustration.

Effects on the blood and immune system

Some chemotherapy drugs affect the bone marrow, which is the soft and spongy material inside the bones. The bone marrow makes three types of blood cells:

  • red blood cells: carry oxygen throughout the body
  • white blood cells: fight infection
  • platelets: help blood to clot and prevent bruising.

The bone marrow’s job is to maintain normal levels of blood cells (your blood count) to keep you fit and healthy. When chemotherapy affects the bone marrow, your blood count is reduced. The count may fall with each treatment. This can cause problems such as anaemia, infections and bleeding problems, depending on the type of blood cell affected.

Your health care team will do regular blood tests to make sure your blood cells return to normal levels before your next treatment.

Anaemia

A low red blood cell count is called anaemia. This can make you feel tired, lethargic, dizzy or breathless.

You may need a blood transfusion to build up your red blood cells and treat the anaemia.

Eating a nourishing diet with foods rich in iron and B vitamins is also important if you are anaemic. Good sources include wholegrain breads and cereals, lean meat and green leafy vegetables.

Infections

If white blood cell numbers drop during chemotherapy, it can make you more prone to infections. Sometimes doctors recommend taking antibiotics as a precaution against infection.

If the number of neutrophils (a type of white blood cell that help protect against infection) drop during chemotherapy, you may be given an injection of granulocyte-colony stimulating factor (G-CSF) after chemotherapy. Your doctor or nurse will speak to you about possible side effects. Some people may experience bone pain or tenderness at the injection site, or show signs of an allergic reaction.

When to contact your doctor

Contact your doctor or treatment centre urgently if any of the following occur:

  • chills or sweats
  • a temperature of 38°C or more
  • persistent or severe vomiting
  • severe abdominal pain, constipation or diarrhoea
  • unusual bleeding
  • redness or swelling around the site of the intravenous chemotherapy device
  • any serious unexpected side effects or sudden deterioration in health.

Also, contact your GP or treating specialist if you experience other symptoms that may be due to an infection. For example, sweating, especially at night; sore throat; mouth ulcers; burning or stinging on passing urine; or easy bruising.

Managing the risk of infections when your immunity is low

  • Check your temperature every day.
  • See your doctor if you are unwell, even if you just have a cold.
  • Wash your hands with soap and water before preparing food and eating, and after using the toilet.
  • Try to eat freshly cooked or prepared foods. Avoid pre-made sandwiches, salads and takeaway; soft cheeses; raw or rare fish, meat and eggs; unpasteurised dairy products and soft-serve ice-creams.
  • Use separate chopping boards and utensils for raw and cooked foods, and clean thoroughly with hot, soapy water.
  • Wash fruits and vegetables well, or peel where possible.
  • Store raw and cooked foods separately.
  • Put leftover food in airtight containers in the fridge as soon as possible.
  • Cook food thoroughly to reduce the risk of bacteria developing.
  • Don’t eat food or drinks past their use-by or best before dates.
  • Avoid people who are unwell, especially if they have the flu, conjunctivitis, measles, mumps, a cold sore or chickenpox.
  • Avoid crowded places such as public transport during rush hour, shopping centres or public pools to reduce the risk of picking up an infection. This is not always practical, so use your commonsense.
  • Check with your doctor about having the flu vaccine if you are having chemotherapy in winter.
  • Let your doctor know if you think you have been in close contact to someone with chicken pox. 

Bleeding problems

A decrease in platelets can cause you to bleed for longer than normal after minor cuts or scrapes, or to bruise more easily. You may need a platelet transfusion if they are low. 

Tips

  • Be careful when using scissors, needles, knives or razors. Small cuts or nicks can harbour germs where an infection can start.
  • Use an electric razor when shaving to reduce the chance of nicking yourself.
  • Wear thick gloves when gardening to avoid injury, and to prevent infection from soil, which contains bacteria.
  • Use a soft toothbrush to avoid irritating your gums.
  • If you bleed, apply pressure for about 10 minutes and bandage, if appropriate.
  • If you have problems with bleeding, talk to your doctor.  

Change in hearing

Some chemotherapy drugs can affect your hearing. Your doctor may recommend that you have a hearing test before you start treatment.

You may be at risk of losing the ability to hear high-pitched sounds. Chemotherapy can also cause a continuous ringing noise in the ears known as tinnitus. While these changes are usually temporary, let your doctor know if you notice any change in your hearing.

Constipation or diarrhoea

 Some chemotherapy drugs, pain relief medicines and anti-nausea drugs can cause constipation or diarrhoea. Tell your doctor or nurse if your bowel habits have changed. 

Constipation

  • Eat more high-fibre foods, such as wholegrain bread and pasta, bran, fruit and vegetables, nuts and legumes (For example, baked beans or lentils).
  • Ease constipation by drinking fruit juice. Try prune, apple or pear juice.
  • Drink plenty of other fluids, both warm and cold, to help loosen the bowels.
  • Do some light exercise, such as walking.
  • Don’t use enemas or suppositories. They are not recommended for people having chemotherapy.
  • Let your doctor or nurse know if you have constipation for more than a couple of days. They may change your medication or give you other medication to relieve it.

Diarrhoea

  • Choose bland foods such as clear broth or boiled rice. Avoid spicy foods, wholegrain products, fatty or fried foods, rich gravies and sauces, and raw fruits or vegetables with skins or seeds.
  • Limit alcohol, fruit juice, soft drinks, strong tea or coffee and dairy products, as these may further stimulate the bowel.
  • Drink water to help replace the fluids lost through diarrhoea.
  • Talk to your pharmacist for advice about using over-the-counter medications to treat diarrhoea at home.
  • If the diarrhoea becomes severe, it can cause dehydration and you may need to be admitted to hospital.

Sex and fertility

Chemotherapy may impact on your desire or ability to have sex. It may also affect sexual organs and functioning in both women and men. This can lead to a temporary or permanent effect on your ability to have children (your fertility).

Changes in sexuality

Many people have a range of worries that cause them to lose interest in sex while they’re having treatment. Aside from feeling tired and unwell, you may feel less confident about who you are and what you can do, or there may be a physical reason for not being able or ready to have sex. For example, vaginal dryness or erection difficulties are common issues after treatment.

Partners may also feel concerned about having sex – they might fear injuring the person with cancer or feel uncomfortable with the changes in their partner. If you have sex after receiving chemotherapy, you should take safety precautions .

Sexual intercourse may not always be possible, but closeness and sharing can still be a part of your relationship. Talk about how you’re feeling with your partner, and take time to adapt to any changes. Try to see yourself as a whole person (body, mind and personality) instead of focusing only on what has changed.

For more information, see sexuality and intimacy.

Changes in fertility

If you want to have children in the future, talk to your doctor about how chemotherapy might affect you and what options are available. Women may be able to store eggs (ova) or embryos and men may be able to store sperm for use at a later date. This needs to be done before chemotherapy starts.

Effects on women

  • For some women, periods become irregular during chemotherapy but return to normal after treatment. For others, chemotherapy may cause periods to stop completely (menopause).
  • After menopause, women can’t have children. Signs of menopause include hot flushes, sweating – especially at night – and dry skin.
  • Menopause – particularly if before age 40 – may, in the long term, cause bones to become weaker and break more easily. This is called osteoporosis.
  • Talk to your doctor about ways to manage menopausal symptoms.

For more information about pregnancy and chemotherapy, see the main Chemotherapy page.

Effects on men

  • Chemotherapy drugs may lower the number of sperm produced and reduce their ability to move. This can sometimes cause infertility, which may be temporary or permanent.
  • The ability to get and keep an erection may also be affected but this is usually temporary. If the problem is ongoing, seek medical advice.

For more information, see sexuality and intimacy.

Contraception

Although chemotherapy reduces fertility, it is still possible for some women to become pregnant while having chemotherapy, and a man having chemotherapy could still make his partner pregnant.

Chemotherapy drugs can harm an unborn baby, so women should not become pregnant during the course of chemotherapy, and men should not father a child. Should you or your partner become pregnant, talk to your treating doctor immediately.

The type of birth control you choose will depend on what you and your partner are comfortable using. Some people use barrier contraception (e.g. condoms), which provide protection against any cytotoxic drug by-products that may be secreted in body f luids. Young women may be prescribed the Pill as a contraceptive and to help protect the ovaries from the effects of chemotherapy.

Nerve and muscle effects

Some drugs can cause tingling and loss of sensation in your fingers and/or toes, and muscle weakness in your legs. If this happens, tell your doctor or nurse before your next treatment. Your treatment may need to be changed or the problem carefully monitored. 

"I had numbness and terrible pain in my hands from one drug. Doing exercises and soaking my hands in warm water helped. The doctors stopped that drug so the side effects wouldn't become permanent." Ann, ovarian cancer

Key points

  • Many people experience side effects from chemotherapy. Side effects are caused when the chemotherapy damages rapidly dividing healthy cells.
  • Most side effects are temporary and gradually go away after you’ve finished treatment.
  • Common side effects include feeling tired, loss of appetite, nausea, mouth sores, digestive problems, hair loss and skin problems.
  • You may also have nerve and muscle effects, hearing changes and a reduced ability to concentrate or remember things.
  • You will also be at an increased risk of infections. This is because chemotherapy can reduce your levels of white blood cells, which are necessary for fighting infections.
  • You may have sexuality and fertility problems, such as reduced sexual desire (libido) or loss of fertility. You might be able to store eggs (ova), embryos or sperm for use at a later date. Talk to your doctor about these issues.
  • Your doctor or nurse will advise you on how to cope with any side effects. You may be given medication or suggestions for eating, drinking and looking after yourself.
  • If you have any side effects that weren’t discussed with you before treatment, let your health care team know so that they can help you.
  • It may be helpful to record your symptoms, when they occurred and what you did to relieve them. Show your notes to your doctor or nurse so they are aware of how the chemotherapy is affecting you.

Information reviewed by: A/Prof Paul Craft, Medical Oncologist, The Canberra Hospital, Medical Oncology, Australian National University Medical School and Clincial Director, Canberra Region Cancer Centre, ACT; Kate Archibald, Clinical Nurse Specialist (Oncology), Monash Health, VIC; Elaine Arnold, McGrath Breast Care Clinical Nurse Consultant, Northern Beaches Health Service, NSW; Ilne Geddes, Consumer; Tina Griffiths, Nurse Coordinator Chemotherapy, Cancer Services, Olivia Newton- John Cancer & Wellness Centre, VIC; and Cecelia van Raders, Team Leader, Cancer Council Helpline, Cancer Council Queensland, QLD.

Updated: 01 Aug, 2014