Chemotherapy affects all cells that grow and divide quickly in the body. This includes cancer cells and normal cells, such as the new blood cells in the bone marrow or the cells in the mouth, stomach, skin, hair and reproductive organs. When chemotherapy damages normal cells, this causes side effects.
Whether or not you experience side effects, and how severe they are, depends on the type and dose of drugs you are given and your reaction from one treatment cycle to the next. Most side effects are short-term and can be managed. They tend to gradually improve once treatment stops and the normal, healthy cells recover. Sometimes, chemotherapy causes long-term side effects that don’t go away. These may include damage to your heart, lungs, nerve endings, kidneys, or reproductive organs.
You may worry about the side effects of chemotherapy. If you feel upset or anxious about how long treatment is taking or the impact of side effects, let your doctor or nurse know. The drugs used for chemotherapy are constantly being improved to give you the best possible results and to reduce potential side effects. This chapter explains ways to manage the discomfort side effects may cause.
Some people have no side effects, others experience a range. If you have side effects, they will usually start during the first few weeks of treatment and may become more intense with each treatment cycle. Before treatment begins, your doctor or nurse will discuss the side effects to watch out for or report, how to help prevent or manage them, and who to contact after hours if you need help.
It can be useful to keep a record of your chemotherapy treatment in one place. This will help you recall details about when you experienced side effects, how long they lasted, and what helped to make them better. You can use a notebook or a diary, or even a smart phone or a tablet.
Share the information you record with your doctors and nurses. They will be able to suggest ways to manage the side effects or, if appropriate, they may adjust your treatment.
Complementary therapies are sometimes used with conventional medical treatments. They may offer physical, emotional and spiritual support, help manage side effects, and improve quality of life.
Some therapies have been proven to be safe and effective in scientific studies. For example, therapies such as meditation, relaxation, massage and counselling can reduce anxiety, and acupuncture can reduce chemotherapy-induced nausea and fatigue. These therapies are part of guidelines for complementary therapies and breast cancer.
It is important to talk to your doctors about any complementary therapies you are using or thinking about trying, as some could interfere with your treatment or make side effects worse. Complementary therapies are different to alternative therapies (ayurveda, homeopathy etc), which are used instead of conventional medical treatments. These are unlikely to be scientifically tested and may prevent successful treatment of the cancer.
Feeling tired and lacking energy (fatigue) is the most common side effect of chemotherapy. Fatigue can include feeling exhausted, drowsy, confused or impatient. You may have a heavy feeling in your limbs, get worn out quickly, 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. While fatigue is a common side effect of chemotherapy, it can also be a symptom of depression.
The treatments you have depend on several factors, including:
* Check with your doctor whether your fatigue is related to low levels of red blood cell (anaemia). Anaemia can be treated.
* Discuss the impact of the treatment with your employer. Some workplaces may allow you to work flexibly during or after chemotherapy. Options include taking a few weeks off, reducing your hours or working from home.
It is common for your appetite to change when you are going through chemotherapy. The drugs may also temporarily change how food tastes. Sometimes you may not feel hungry or you may prefer different types of food.
Chemotherapy can make you feel sick (nauseated) or cause you to vomit. Not everyone feels sick during or after chemotherapy, but if nausea affects you, it will usually start 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.
Often the best way to manage nausea is to prevent it from starting. Anti-nausea (antiemetic) medicine helps most people, but finding the right one can take time. If nausea or vomiting continues after using the prescribed medicine, let your nurse or doctor know so that another medicine can be tried. Steroids may also be used to manage nausea.
Being unable to keep liquids down because of vomiting can cause you to become dehydrated. Signs of dehydration include a dry mouth and skin, dark urine, dizziness and confusion. It is not safe to be left alone if you are vomiting a lot, as the confusion may make it difficult to realize you have become seriously dehydrated.
| Managing Nausea | Managing Appetite Loss |
|---|---|
| Eat a light, bland meal before your treatment (e.g. soup with dry biscuits, crackers or toast). | Eat what you feel like, when you feel like it. Have frequent snacks instead of large meals. |
| Keep sipping fluids so that you don’t get dehydrated. If you aren’t able to keep fluids down, contact your doctor or hospital immediately. | Try to eat extra on days when you have an appetite. |
| Sip fluids throughout the day. Sucking on ice cubes can also increase your fluid intake. If water tastes unpleasant, flavour it with ginger, mint, lime etc. | Avoid strong odours and cooking smells that may put you off eating. |
| If your stomach is upset, try drinking fizzy drinks such as soda water or dry ginger ale or ginger tea. | If the taste of certain foods has changed, don’t force yourself to eat them. Your sense of taste should return to normal after treatment ends. |
| If you wake up feeling sick, eat a dry biscuit or slice of toast rather than skipping food. | If you don’t feel like eating solid foods, try enriching your drinks with powdered milk, yoghurt, eggs or honey. |
| Don’t use nutritional supplements without your doctor’s advice, as some could interfere with treatment. | |
| Ask a dietitian for advice on the best eating plan during treatment and recovery. |
Some chemotherapy drugs, pain medicines and anti-nausea drugs can cause constipation or diarrhoea. Inform your doctor or nurse if your bowel habits have changed.
| Constipation | Diarrhoea |
|---|---|
| Eat more high-fibre foods, such as wholegrain bread and pasta, bran, fruits and vegetables, nuts and legumes (e.g. baked beans or lentils). | Choose bland foods such as clear broth or boiled rice. |
| Drink plenty of fluids, both warm and cold, to help loosen the bowels. Prune, apple or pear juice can work well. | Avoid spicy foods, wholegrain products, fatty or fried foods, rich sauces, and raw fruits or vegetables with skins or seeds. |
| Do some light exercise, such as walking. | Limit alcohol, fruit juice, soft drinks, strong tea or coffee, and dairy products, as these stimulate the bowel. |
| Ask your doctor about using a laxative, stool softener and/or fibre supplement. | Drink water to help replace fluids lost through diarrhoea. |
| Avoid enemas or suppositories as they may cause infection. | Talk to your cancer care team – they may change the treatment or suggest other solutions, such as using over-the-counter medicines. |
| Let your treatment team know if you have constipation for more than a couple of days. They will be able to help | If diarrhoea is severe, let your cancer care team know. It can cause dehydration and you may need to go to hospital. |
# WATERY EYES can be a symptom of a blocked tear duct. This can be caused by some chemotherapy drugs. Regularly massaging the area and using eye drops can help clear blockages.
Many people having chemotherapy worry about hair loss (alopecia). Whether or not you lose your hair will depend on the drugs you are prescribed. Some people lose all their hair quickly and others lose it after several treatments, while others may lose only a little hair or none at all. Although losing head hair is most common, you may find your eyebrows and eyelashes fall out, and you may lose hair from your underarms, legs, chest and pubic region.
When hair loss does occur, it usually starts 2–3 weeks after the first treatment. 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. After chemotherapy ends, 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 original condition.
Many people find losing their hair difficult. Your hair may help form part of your sense of self – its loss can affect your self-confidence and make you feel sad or vulnerable. For many people, it’s a public sign of the cancer diagnosis. Talking to your treatment team may help.
Some people may be able to reduce or prevent hair loss by using a “cold cap”. This works by temporarily reducing the blood flow and the amount of chemotherapy drug that reaches the scalp. A cap is worn on the head and attached via a hose to a cooling unit, which fills the cap with cold liquid. It is worn while the chemotherapy is delivered.
The cold cap can only be used with certain drugs and types of cancer ,and doesn’t always prevent hair loss. Check with your doctor or nurse whether a cold cap would be an option for you and whether it is available at your treatment centre.
Some chemotherapy drugs can cause mouth sores, such as ulcers, or infections. This is more likely if you have had or are having radiation therapy to the head, neck or chest, or if you have dental or gum problems.
If you notice any sores, ulcers or thickened saliva, or if you find it difficult to swallow, tell your doctor.
Some chemotherapy drugs may cause your skin to peel, darken or become dry and itchy. During treatment and for several months afterwards, your skin is likely to be more sensitive to the sun.
Some people find their nails also change and become darker than usual, or develop ridges or white lines across them. Your nails may also become brittle and dry. These changes usually grow out.
Some people say they have difficulty concentrating, focusing and remembering things after they have had chemotherapy. This is called cancer-related cognitive impairment or, sometimes, “chemo brain” or “cancer fog”. Thinking and memory changes may be caused by treatment or medicines, fatigue and sleep problems, or emotional concerns, such as stress or depression. These problems usually improve with time, although some people experience issues for years.
Tell your doctor about any thinking and memory changes you are having, and if this issue is affecting your day-to-day life or your return to work.
Blood cells are made in the bone marrow, which is the spongy part in the centre of the bones. The bone marrow makes three main types of blood cells, which have specific functions:
Because the new blood cells are rapidly dividing, they can be damaged by chemotherapy, and the number of blood cells (your blood count) will be reduced. Low numbers of blood cells may cause anaemia, infections or bleeding problems.
You will have blood tests at the beginning of treatment and before each chemotherapy cycle to check that your blood count has returned to normal before you have chemotherapy.
If your red blood cell count drops, a reduced amount of oxygen circulates through your body. This can cause anaemia, which can make you feel tired, lethargic, dizzy or breathless. To minimize dizziness, take your time when you get up from sitting or lying down.
Your treatment team will monitor your red blood cell levels. Let them know if you experience any symptoms of anaemia while having chemotherapy. If the levels of red blood cells drop too low, you may need a blood transfusion to build them up again.
If white blood cell numbers drop during chemotherapy, it can lower your immunity. This makes you more likely to get infections and less able to fight any infections that do occur. Your doctor may recommend antibiotics as a precaution against infection.
Many types of white blood cells make up the total white cell count. A type of white blood cell known as a neutrophil protects you against infection by destroying harmful bacteria and yeasts that enter the body. During chemotherapy, some people get low levels of neutrophils. This is known as neutropenia.
If you have neutropenia, you may be given an injection of growth factor drugs called granulocyte-colony stimulating factor (G-CSF) after chemotherapy to encourage the bone marrow to make more white blood cells. 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.
During chemotherapy treatment, even a minor infection could become serious quickly. See below for when you need to contact your doctor urgently.
Reduce your risk: To prevent the spread of infection:
Contact your doctor or go the nearest hospital emergency department immediately if you experience any of the following:
Platelets are the blood cells that help the blood to clot. A low level of platelets (thrombocytopenia) can cause problems with bleeding. You may bleed for longer than normal after minor cuts or scrapes, have nosebleeds or bleeding gums, or bruise easily.
Your treatment team will monitor your platelet levels. If chemotherapy causes thrombocytopenia, you may need a platelet transfusion. Ask your oncologist to explain the risks and benefits of platelet transfusion. Contact your treatment team for persistent bleeding, such as a nosebleed that does not stop within 30 min.
If your symptoms are severe, talk to your doctor about medicines that may offer relief.
Chemotherapy can have an impact on your desire (libido) or ability to have sex. It may also affect sexual organs and functioning in men and women. This can affect your ability to have children (fertility).
Chemotherapy can have an impact on your desire (libido) or ability to have sex. It may also affect sexual organs and functioning in men and women. This can affect your ability to have children (fertility).
A range of issues can cause people 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. There may also be a physical reason for not being able or interested in sex, e.g. vaginal dryness or erection difficulties. Changes in appearance can also affect feelings of self-esteem and, in turn, sexuality.
If you have a partner, it may be helpful for them to understand the reasons why your libido has changed and to know that people can have a fulfilling sex life after cancer, but it often takes time. Some 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, follow the contraception recommendations outlined below.
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. If you’re worried about the changes to your relationships or sexual functioning, you may find talking to a psychologist or counsellor helpful.
Your doctor may talk to you about using contraception during and after chemotherapy. Although chemotherapy often affects fertility, this doesn’t mean it rules out pregnancy. Some women can still 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 plan to avoid becoming pregnant during chemotherapy treatment, and men should not father a child. If you or your partner become pregnant, talk to your specialist immediately.
The type of birth control you choose will depend on what you and your partner are comfortable using. Some people use barrier contraception such as a condom or female condom, which provides protection against any chemotherapy drugs that may be present in their body fluids.
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 and requires careful consideration.
Chemotherapy can reduce the levels of hormones produced by the ovaries. For some women, this causes periods to become irregular during chemotherapy but they return to normal after treatment. For other women, chemotherapy may cause periods to stop completely (menopause). After menopause, women can’t conceive children. Signs of menopause include hot flushes, sweating (especially at night), and dry skin. Menopause – particularly when it occurs in women under 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.
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 have and keep an erection may also be affected, but this is usually temporary. If the problem is ongoing, talk to your doctor.
| Why side effects occur | Many people experience side effects from chemotherapy. Side effects are caused when the chemotherapy damages rapidly dividing healthy cells. |
| Common Side effects | Fatigue Loss of appetite Nausea Bowel issues (constipation or diarrhea) hair loss Mouth sores Skin and nail problems. Concentrating or remembering things Nerve and muscle effects Hearing changes. Infections. Sexual problems, such as reduced sexual desire or loss of fertility. |
| Most side effects are temporary and gradually improve after you have finished treatment | |
| Managing Side effects | • Your doctor or nurse will advise you on how to cope with any side effects. • You may be prescribed medicine or given 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 |