Understanding and Managing Chemotherapy Side Effects

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and Managing
Side Effects
Presented by
Richard J. Gralla, MD
Multinational Association of Supportive Care in Cancer
Nancy G. Houlihan, RN, MA, AOCN®
Memorial Sloan-Kettering Cancer Center
Carolyn Messner, DSW
Learn about:
• Common side effects
• Practical information
• Improving quality of life
• The role of your health care team
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Understanding and
Managing Chemotherapy
Side Effects
Presented by
Richard J. Gralla, MD
Past President, Multinational Association of
Supportive Care in Cancer
New York, New York
Nancy G. Houlihan, RN, MA, AOCN®
Clinical Nurse Specialist, Survivorship Program
Memorial Sloan-Kettering Cancer Center
New York, New York
Carolyn Messner, DSW
Director of Education and Training
The information in this booklet is based on a Connect® Education
Workshop conducted by CancerCare.
page 2
n FATIGUE, page 5
n NERVE DAMAGE, page 8
n INFECTIONS, page 9
n DIARRHEA, page 11
n HAIR LOSS, page 14
page 17
GLOSSARY (definitions of blue boldfaced words in the text)
page 19
page 20
This CancerCare Connect® booklet was supported
by an educational donation provided by Amgen.
page 20

With better control of
chemotherapy side effects,
cancer treatment is going more
smoothly for many patients.
As most people know, the goal of chemotherapy is to
destroy cancer cells. Traditional chemotherapies work by
killing cells that divide rapidly. As they wipe out fast-growing
cancer cells, though, they can also damage fast-growing
normal cells.
For example, damage to blood cells leads to side effects
like anemia, fatigue, and infections. Chemotherapy can also
damage the cells that line the mucous membranes found
throughout the body, such as those inside the mouth,
throat, and stomach. This leads to mouth sores, diarrhea, or
other problems with the digestive system. And damage to
cells in the hair follicles leads to hair loss.
Each person with cancer reacts differently to chemotherapy
and its various side effects. Fortunately, doctors now have
many ways to reduce and even prevent these side effects. In
this booklet, you’ll find practical information on managing side
effects so that your treatment goes as smoothly as possible.
You should note that there are newer medications, not
discussed in this booklet, known as targeted treatments.
They generally cause less severe side effects than traditional
chemotherapy. Many people taking these drugs develop a
skin rash and other bothersome skin and nail conditions.
Patients most likely to be affected are those taking a
particular type of targeted treatment called an EGFR
inhibitor. You can learn more about how to cope with skin
rash from targeted treatments in the CancerCare Connect®

When Chemotherapy
Damages Blood Cells
Even as chemotherapy kills cancer cells, it also damages
fast-growing normal cells in the body such as:
White blood cells These cells help fight infections and
are an important part of our immune
defense system. A low white blood
cell count, called neutropenia, can
increase the risk of infection.
Red blood cells These doughnut-
shaped iron-containing cells carry vital
oxygen from the lungs to the muscles
and other tissues in the body. A low
red blood cell count, called anemia,
can lead to fatigue, weakness, and
difficulty breathing.
Platelets These structures in the
blood help stop bleeding by plugging
leaks in the blood vessels. Low levels of platelets lead to a
condition known as thrombocytopenia, which can cause
bruising or bleeding.
booklet Tips for Managing Treatment-Related Rash and Dry 
Obtain a free copy by downloading the book at
www.cancercare.org or by calling 1-800-813-HOPE (4673).
Nausea and Vomiting
When it comes to nausea and vomiting, we know that:
n Younger people are at higher risk than older people.
n Women are at a slightly higher risk than men.
n Certain drugs commonly cause these side effects,
including cisplatin (Platinol and others), doxorubicin

Coping With Nausea
These tips can help:
n Eat and drink slowly. Try having small meals throughout
the day instead of your usual breakfast, lunch, and dinner.
n Avoid sweet, fried, or fatty foods, as
well as foods with strong odors. Eating
foods cold or at room temperature can
help you avoid strong smells.
n Be sure that you fully understand your
doctor’s and nurse’s instructions for
taking anti-nausea medicines.
n See that you have a sufficient supply of
the correct drugs.
n Be sure that you are drinking enough
fluids. Ask your nurse or doctor about
proper nutrition during this time.
n Find out from your doctor if any other medicines you may
be taking require special precautions.
(Adriamycin and others), and cyclophosphamide. Doctors
have used these standard chemotherapies for many years.
Many surveys have shown that patients and their family
members believe that nausea and vomiting occur with all
types of chemotherapy. More than 20 years ago that was
true, and it was difficult to control the symptoms. Today,
doctors do a much better job of preventing and easing these
symptoms. Generally, if there’s more than a 10 percent risk
of causing nausea or vomiting with chemotherapy, patients
are given anti-nausea medicines — also known as anti-
— as a preventive.
The most common form of anti-nausea medication is a

combination of dexamethasone (a type of steroid) and a
serotonin blocker — a compound that stops the natural
substance serotonin from sending a message to the brain
that triggers nausea. Serotonin blockers include dolasetron
(Anzemet), granisetron (Kytril and others), ondansetron
(Zofran and others), and palonosetron (Aloxi).
This combination helps prevent the acute nausea
and vomiting
that can occur in the first 24 hours after
chemotherapy. Doctors usually recommend patients
continue using this drug combination for two to three days
following treatment to prevent delayed nausea. By taking
medication to prevent these different types of nausea,
patients also can avoid developing anticipatory nausea — the
queasy feeling that can come before chemotherapy.
Aprepitant (Emend) is an anti-emetic drug that can be
added to the combination of dexamethasone and a
serotonin blocker to protect against both acute and delayed
nausea and vomiting. Aprepitant, taken as a capsule, works
by counteracting the effects of a chemical produced in the
body called “substance P.”
A related drug, fosaprepitant (Emend for Injection), gives
patients receiving chemotherapy another option for
preventing nausea and vomiting. Delivered intravenously,
fosaprepitant is converted to aprepitant in the body.
There are many options available to help you manage
nausea and vomiting. Talk with your doctor about which one
is best for you. Remember, anti-nausea medicines are given
to prevent the problem from occurring.
Feeling tired — really tired — can be tied to a number of
n The cancer itself
n Treatment of the disease

Dealing With Fatigue
These tips can help you reduce your fatigue:
n Take several short naps or breaks in a comfortable chair
rather than in bed.
n Take short walks or do some light exercise if possible.
n Try easier or shorter versions of the activities you enjoy.
n Ask your family or friends to help you with tasks you find
difficult or taxing.
n Save your energy for things you find most important.
n The emotional aspects of dealing with cancer and cancer pain
n Anemia (low levels of red blood cells)
If you are experiencing fatigue, you should know that this is
a symptom for which you can and should seek help. If your
doctor doesn’t ask you about fatigue, be sure to bring it up.
That’s the best way to find and treat the cause.
To determine whether there is an underlying physical
cause, your doctor will order a blood test to find out if your
red blood cell count is abnormally low (anemic). If you
are anemic, there are many treatment options. Oncology
social workers and oncology nurses can also help you
manage fatigue. They can work with you to address any
psychological concerns that may be causing symptoms and
help you develop practical strategies for coping.
Don’t try to treat yourself with over-the-counter medicines for
“iron-poor blood.” These drugs have not proved to be helpful.

Mouth Sores (Mucositis)
Sores inside the mouth and on the lining of the throat and
digestive tract can result from radiation treatments and

from some types of chemotherapy. Mucositis can be a
serious problem because it can cause pain and infections,
making it difficult to eat, drink, and swallow. Once treatment
ends, mouth sores do disappear. But before they fade, it’s
important that you work closely with your health care team
to manage this side effect of cancer treatment. Here are
some of the most important steps:
Visit your dentist before treatment. A small problem
could turn into a large one if mouth sores develop later on.
Take care of your mouth and keep it clean.
n Use the softest bristle brush.
n If toothpaste irritates your mouth,
use a mixture of ½ teaspoon salt
with 4 cups water.
n Gargling may help. Use a solution
made up of:
1 quart plain water
½ teaspoon table salt
½ teaspoon baking soda
Drink plenty of fluids.
Soothe mouth sore pain with:
n Ice chips or Popsicles.
n Ibuprofen (such as Motrin) or
acetaminophen (such as Tylenol) for mild pain.
n Over-the-counter anesthetics, such as Anbesol or Orajel.
Let your doctor know if you are using them, especially if
he or she prescribes a lidocaine-based mouthwash.
n Gelclair — an oral gel designed to coat and soothe mouth
sores by forming a protective barrier in the mouth. This is
available by prescription only.
If you are receiving high-dose chemotherapy followed
by bone marrow transplant for a blood cancer, the drug


palifermin (Kepivance) may be prescribed. Palifermin,
given intravenously, has been shown to protect the lining
of the mouth, reducing severe mucositis. The safety and
effectiveness of this drug for people with other types of
cancer are not yet known.
Don’t resist taking stronger drugs for severe pain.
For example, opiates, a class of drugs that includes
morphine, may be prescribed to help you cope with mouth
pain. It’s important to manage pain because it can affect
your quality of life and even slow progress toward better
health. If swallowing pills is difficult, severe pain can be
treated with intravenous drugs. And when your pain is
controlled, you will be better able to eat and drink fluids.
Nerve Damage
Some people on chemotherapy experience pain, numbness,
or tingling in their hands and feet, what doctors call
peripheral neuropathy. Symptoms related to neuropathy and
other types of nerve damage can include:
n Difficulty picking up objects or buttoning clothing
n Problems with balance
n Difficulty walking
n Jaw pain
n Hearing loss
These symptoms can build over time. Some people don’t
notice them until they have had several chemotherapy
treatments. It’s important to tell your doctor as soon as
possible if you experience these types of side effects. He
or she may want to adjust some of your medicines or
chemotherapy and may want to see if there is another
reason for the problem that can be treated.
Often, nerve damage is temporary; it will usually get better,
but it can take time. That’s because the nerve fibers re-grow