Side effects of chemotherapy

Thursday 1 April, 2010

Reviewed by: Assoc. Prof. Ian Davis MB BS (Hons) PhD FRACP FAChPM, Medical Oncologist, Austin Health. Assoc. Member, Ludwig Institute for Cancer Research; Dr Anthony Dowling, Medical Oncologist, St Vincent's Hospital 

On this page: Fatigue | Nausea and vomiting | Bowel problems | Mouth problems | Hair loss and scalp problems | Cognitive problems ('chemo brain') | Effects on the blood | Muscle and nerve effects | Fertility

Contact your doctor or chemotherapy nurses urgently if you experience:

  • fever over 38°C (100 °F), chills or sweats
  • easy bruising or any abnormal bleeding
  • persistent or severe vomiting: vomiting so often that you can't keep liquids down, despite taking the medication prescribed to you for vomiting
  • severe constipation, diarrhoea (more than 3 extra bowel actions per day, especially if loose or watery) or pain in your abdomen.
  • a sudden decline in health.

The most important effect of chemotherapy is that it destroys cancer cells. But it may also cause unwanted side effects. Fortunately, most side effects go away in time, and there are ways to reduce and manage the discomfort they may cause.

Side effects vary considerably. Two people on the same treatment may react quite differently. Some people have no side effects. Reactions can also vary from one period of chemotherapy to the next.

Remember that the type and severity of side effects have nothing to do with the success of your treatment. If you've chosen to have chemotherapy it's best to talk to your doctor about side effects you should watch out for or report before your treatment begins about side effects you should watch out for or report. It's also helpful if you know how the side effects may be managed.

The most common side effects of chemotherapy are fatigue (tiredness), nausea (feeling sick) and vomiting, bowel problems, mouth problems, hair loss and scalp problems and effects on the blood. These are discussed in more detail below.

During your treatment, tell your doctor or nurse of any side effects you notice. It may be useful to keep a chemotherapy journal  while you're having treatment, and write down any side effects you have. If you have a severe side effect, the doctor may suggest a break in your treatment, or change the kind of treatment you're having.

Don't use any medicines or home remedies without talking to your doctor or chemotherapy nurse first. They could change the effect of chemotherapy in your body, making it less effective or making side effects worse. Even things you might think are simple and harmless, like vitamins, herbal supplements or anti-oxidants, can have harmful effects when used with cancer treatments.

Side effects may occur during and after the treatment. Awareness of the possible side effects makes it easier to prepare for and cope with them. The following sections describe the most common side effects.

Fatigue

Fatigue is a common side effect of chemotherapy. The cancer itself can also cause fatigue. Fatigue can include feeling exhausted, tired, sleepy, drowsy or impatient. If you're fatigued you'll lack energy and may have trouble paying attention or concentrating.

Fatigue can appear suddenly and be overwhelming. It's not always relieved by rest. It can continue after treatment ends. 

Cancer and its treatment can cause anaemia (reduced red blood cells), which results in fatigue.  Your blood cell counts will be monitored by regular blood tests.  If you do develop anaemia, your doctor may recommend a blood transfusion to improve your red blood cell count.  This can help reduce fatigue.

Try to plan your day so that you can get the things done that you need to do, without being too rushed. Plan to exercise if you are able to: exercise will help you stay fit and maintain your strength and can reduce fatigue. Try not to push yourself to do more than you can comfortably do. Taking short naps or breaks, eating well and drinking plenty of fluids may help.

Don't be afraid to ask other people for help. Family, friends and neighbours may be glad of the chance to help you, with tasks like picking up the kids from school, shopping and mowing the lawn. 

Nausea and vomiting

Chemotherapy can cause nausea (feeling sick).

To try to avoid nausea, before your treatment eat only a light meal (for example, soup and dry biscuits) and drink as much fluid as possible. After treatment, have regular small drinks rather than large drinks. Drink whatever non-alcoholic fluids you prefer: cordial, juice, soda water, dry ginger and weak tea are refreshing. Ice cubes, icy-poles or jellies are other ways to have fluids.

Anti-nausea medication can help. It will probably be given with your chemotherapy. If nausea is likely, you'll be given anti-nausea tablets to take at home and may be advised to have a tablet at home before your next treatment. Anti-nausea suppositories are sometimes used. These are placed in the rectum (or back passage) where they dissolve.

If you're feeling ill, don't eat rich or fatty foods. They may make it worse.

Several anti-nausea medications are available. It may take some time before you find the one that is right for you, but keep trying - nausea and vomiting can be reduced with treatment. Ask your doctor, nurse or pharmacist how you should take your medicines.

Contact your doctor if you still have nausea or vomiting despite taking the medication prescribed for you.

Bowel problems

Constipation may be avoided if you eat high fibre foods such as wholegrain bread and pasta, bran, fruit and vegetables. It's important to also drink plenty of fluid. Use a laxative if you need to: ask your doctor or nurse which type you could use. Enemas and suppositories for constipation are not advised. Some anti-nausea medications cause constipation.

Some chemotherapy may cause severe diarrhoea, which can lead to dehydration and serious complications. If you're receiving one of these treatments, your doctor should advise you what to do if diarrhoea develops. It may first be treated with medication at home but if the diarrhoea is severe you may need to be admitted to hospital. If you have more than 3 extra bowel actions a day, especially if they're loose or watery or contain blood, contact your doctor for advice.

Avoid dairy products while you have diarrhoea and increase your intake of fluids to avoid dehydration. After the diarrhoea has cleared up, it's important for you to return to a balanced diet that includes fresh fruits, vegetables and wholegrain cereals.

You should report any problems with severe diarrhoea, severe constipation or stomach pain to your doctor. 

Mouth problems

Some chemotherapy drugs can affect the lining of the mouth and sometimes cause mouth ulcers or infections. Some people are more likely to have problems than others. Ask your doctor or nurse whether you need to take extra care.

Good mouth care is important for everyone having chemotherapy. Good mouth care includes:

  • flossing your teeth carefully once a day
  • brushing your teeth and gums after meals and at bedtime using a fluoride toothpaste and a soft toothbrush - an electric toothbrush is ideal
  • rinsing your mouth with water after flossing and brushing. 

You may be given special mouthwashes to try to prevent mouth infections such as thrush. Don't use commercial mouthwashes without first asking the doctor. Sometimes they contain alcohol, which can irritate your mouth. A teaspoon of salt in a glass of warm water (‘swish and spit') will help to keep your mouth healthy: use at least 4 times a day.

Try eating warm or cool foods rather than hot foods. Avoid spicy foods. If you have a dry mouth it may help to sip fluids, especially water, or suck on ice chips. Moisten foods with gravies, sauces or butter. It may also help you to chew sugar-free gum or consider a saliva substitute, oral gel or dry mouth tooth-paste.

If you notice any change in your mouth or throat, such as ulcers or thickened saliva, or find it difficult to swallow, contact your doctor or chemotherapy nurse.

Discuss any dental problems with your doctor. Before you have any dental treatment, tell your dentist that you're having chemotherapy.

Hair loss and scalp problems

Hair loss or thinning is caused by some drugs that temporarily damage the hair. Many drugs don't cause hair loss.

Some people lose all their hair very quickly, others lose it after several treatments, while others lose only a little hair or no hair at all. When hair loss does occur, it usually starts two to three weeks after treatment begins. Your scalp can be tender before hair loss and while your hair is falling out.

Although the head hair is most often lost, some people also lose some or all of their body hair (for example, hair on arms or legs and pubic hair). Hair loss caused by chemotherapy is not permanent. Your hair will regrow either during treatment or after you have finished treatment.

If it is expected that you will lose your hair, and you would like a wig, your doctor or nurse will help you. If you want to buy a wig, your nurse or social worker may be able to tell you how to get financial help to do so. Some people find it more comfortable to wear a hat or scarf.

Some chemotherapy drugs make you more likely to get sunburn. Remember to protect your head against sunburn and extreme cold. If your eyelashes fall out, wear glasses or sunglasses to protect your eyes on windy days.

To care for your hair and scalp:

  • keep your hair and scalp clean
  • use a baby shampoo or another very mild shampoo
  • comb or brush your hair gently. Use a large comb or a hairbrush with soft bristles
  • If possible, use a cotton, polyester or satin pillowcase; nylon may irritate your scalp.

Some people have their hair cut short before or during chemotherapy, so any change is not too dramatic.

Avoid hair perms and dyes, which may increase hair loss. Also avoid daily use of hair dryers and rollers and gels, mousses and hair sprays. In time you will be able to resume your usual hair care routine. This usually happens over months.

When your hair first grows back it may be a little different. Sometimes it will be curly even though it used to be straight. In time your hair will probably return to what it was like before.

Discuss any concerns with your doctor or nurse.

Look Good, Feel Better is a program for women having chemotherapy or radiotherapy, to manage some of the physical effects of treatment. Call 13 11 20.

Cognitive problems ('chemo brain')

After chemotherapy many people say they find it hard to concentrate, focus and remember things. This is often called ‘chemo brain'. It can be very frustrating, especially if you need to concentrate on fine detail, for example in your work or study.  People who have always been able to concentrate well may find the changes embarrassing and hard to cope with. It may help to know that ‘chemo brain' can happen to anyone who has chemotherapy.

Researchers are trying to discover what causes these memory and concentration problems. It is not clear if these problems are caused by chemotherapy alone. The problems usually get better with time, but it may take a year or more. Some of the following tips may help:

  • Use a calendar or daily planner to keep track of tasks, appointments, social commitments, birthdays, etc.
  • Make lists of things you have to remember: things you need to do that day, things you need at the shops, even where you parked the car.
  • See if ‘exercising your brain', for example by reading, crosswords, puzzles, study or doing a hobby helps you to concentrate more.
  • Plan your activities so you do things that require more concentration when you are more alert, such as in the morning.
  • Get plenty of sleep and exercise. Deep sleep is important for memory and concentration. Exercising every day will help you sleep better.
  • If your ‘chemo brain' affects your study or work, let your supervisor or manager know. See if project deadlines, performance reviews and so on can be rescheduled.

Try to be patient. Talking to others, for example, your partner, manager and colleagues, can help to prevent misunderstanding and frustration.

Effects on the blood

The bone marrow acts as the ‘factory' for making white blood cells, red blood cells and platelets. Its job is to maintain normal levels of blood cells (this is called the blood count) to keep you fit and healthy.

Most types of chemotherapy will affect the bone marrow so that your blood count is reduced. The count may fall with each treatment. You will have regular blood tests to make sure that your blood counts are high enough for your next treatment.

Sometimes, a low blood count causes problems. These are related to the type of blood cell affected.

Infection

Chemotherapy may reduce your white blood cells. White blood cells are important for fighting infection. So if your white blood cells are low while having chemotherapy (neutropenia), bacteria that normally live in or on the body may multiply and cause a fever. You can't totally avoid infection, but avoid people with obvious coughs and colds.

See your doctor immediately if you're unwell or your temperature is higher than 38° C (100° F).

If you're having chemotherapy in winter, check with your doctor about having a flu injection.

Granulocyte-colony stimulating factor (G-CSF) is a treatment given by injection to some people after chemotherapy. It helps to increase the number and function of a type of white blood cell (called ‘neutrophils'), which help to protect us against infection. G-CSF is not prescribed for everyone. Check with your doctor if it's an option for you.

The discoveries that make G-CSF treatment possible were made in Melbourne by Donald Metcalf, a research Fellow funded by Cancer Council Victoria.

Bleeding problems

Your platelets help the blood to clot. Chemotherapy can cause a fall in the number of platelets (thrombocytopaenia). This can cause you to bleed for longer than normal or you may bruise easily. You may need a blood transfusion if your platelets are low.

Anaemia

Red blood cells carry oxygen to the body's tissues. If the red blood cells are low due to chemotherapy, anaemia can occur. This can make you feel weak and tired and look pale. You may need a blood transfusion.

How to guard against the effects on the blood

Changing your diet will not stop the blood lowering effects of chemotherapy, however a well balanced diet is recommended.

Report any unusual symptoms to your doctor. These may include excessive tiredness, bruising or bleeding easily. If you have a fever over 38 °C (100 °F), contact your doctor or nurse immediately, day or night. You should have a thermometer at home to monitor your temperature and know how to use it.

Let your doctor know if you're in contact with chickenpox. It's sometimes necessary to have an injection to guard against getting chickenpox or shingles.

Muscle and nerve effects

Some drugs can cause tingling and loss of feeling in the fingers and/or toes, muscle weakness (particularly in the legs), or a change in hearing or ringing in the ears. If this happens, let your doctor or nurse know before your next treatment. A slight change in the treatment might be necessary.  

Fertility

Chemotherapy may have a temporary or permanent effect on fertility.

Some women who are still having periods before starting chemotherapy may have irregular periods during chemotherapy. They may become regular again after treatment finishes. For other women, chemotherapy can cause premature menopause. This means having to deal with the short-term and long-term effects of menopause. Short-term effects include hot flushes, night sweats and dry skin. Early menopause can also lead to concerns about bone strength, bone mineral density and heart disease. After menopause, women can't have children. It can be difficult to consider menopause, while dealing with your cancer.

Although the chance of a pregnancy in the future may be reduced following chemotherapy, many women are still able to have children. You may be able to store eggs or part of an ovary for future use before starting chemotherapy: ask your doctor about this. Its success has not been fully established and it's only available in some cancer treatment centres. 

In men, chemotherapy may reduce sperm production. This reduction in sperm numbers can range from very mild to very severe (where sperm are no longer made) and the effect can be temporary or permanent. Some men may consider having sperm stored before treatment starts for use at a later date if desired.

You should discuss these issues with your doctor before chemotherapy.

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