Side Effect Management

Side Effects of Chemotherapy

Can the dose be reduced if I have a lot of side effects?
It is very important to try to maintain the highest tolerable dose during chemotherapy treatment. Studies have shown that reducing the dose or delaying chemotherapy treatments until side effects subside may decrease the likelihood of cure and the chances for long-term survival in some types of lymphomas. It is important for you as a patient to understand that changing the regimen to reduce short-term side effects may actually be harmful in the long run. However, your present quality of life is valuable as well, and you need to decide whether the side effects are tolerable or not. It is important to make this decision in an informed way and understand the potential consequences of your choice.

What are the side effects of chemotherapy?
Many people are frightened by the side effects of chemotherapy. However, it is important to understand that:

  • Not all patients who receive chemotherapy experience side effects;
  • Side effects are not always severe, they can be mild;
  • Different chemotherapy drugs have different side effects;
  • Doctors are familiar with chemotherapy side effects and can treat them so they are less severe and, sometimes, even prevent them from happening altogether.

Many of the side effects caused by chemotherapy are due to the effect the medications have on the healthy, non-cancerous cells of the body. The following table outlines the most common cell types affected as a result of chemotherapy, as well as the resulting side effects.

Cells Affected Associated Side Effects
Cells of the digestive system including the mouth, esophagus, stomach and intestines
  • Mouth sores
  • Sore throat
  • Diarrhea
  • Nausea
  • Vomiting
  • Changes in taste
  • Loss of appetite
Cells of the skin and hair
  • Hair loss
Cells of the bone marrow; red blood cells, white blood cells and platelets Decreased blood cell production (myelosuppression), including:
  • Anemia (decrease in red blood cells)
  • Neutropenia (decrease in white blood cells)
  • Thrombocytopenia (decrease in platelets)

 

Mouth Sores and Sore Throat

What is it?
Mouth sores occur when the inside of your mouth becomes red, sore and irritated. It is often called mucositis. Your throat may also be sore. Infections of the mouth and throat may occur. If you have a persistently sore mouth or throat you should tell your doctor.

What can I do?
There are a number of things you and your doctor can do to prevent and treat mouth sores:

  • Clean your teeth gently after each meal with a soft, nonabrasive toothbrush.
  • Use lip moisturizer to avoid dry, irritated lips.
  • Avoid mouthwashes that contain alcohol.
  • Avoid citrus fruits, citrus juices and spicy foods.
  • Rinse your mouth frequently with a salt and water combination or club soda (an easy-to-use salt and water combination).
  • Eat softer foods so they are easier on the moist tissues of your mouth.
  • Avoid flossing your teeth if your blood cell counts are low.

Diarrhea

What is it?
Frequent and watery bowel movements.

What can I do?
The most important consequence of diarrhea is dehydration (loss of body fluids). To avoid dehydration, the following tips may be useful:

  • Drink plenty of water throughout the day.
  • Avoid milk products as they may worsen your diarrhea.
  • Pay attention to the signs of dehydration: dry mouth or skin, decreased urination, and dizziness or lightheadedness upon standing.
  • Take the medications your doctor recommends for controlling diarrhea.

Nausea and Vomiting

What is it?
Chemotherapy can often be associated with both nausea (the urge to vomit) and vomiting. Nausea most commonly occurs on the day you receive the chemotherapy but can also occur in the few days following treatment.

What can I do?
Your doctor may prescribe an antiemetic (a drug that prevents vomiting) or an antinauseant (a drug that prevents nausea) to take before you begin chemotherapy. This can often prevent both the nausea and vomiting from occurring. If you do experience these symptoms, the following are ways to control them:

  • Consume mostly liquids for the first one to two days after your chemotherapy treatment (returning to solid foods once the feeling has subsided); soups are a good choice including broths or consommés; however, avoid milk-based soups.
  • Avoid foods that are too hot, sweet or spicy.
  • Eat smaller meals more frequently throughout the day instead of three large meals.
  • Get plenty of fresh air and try to avoid strong or unpleasant odours.
  • If you do experience vomiting, be sure to stay hydrated (see the tips in the diarrhea section).
  • Take the antiemetic/antinauseant medication prescribed by your doctor.

Changes in Taste

What is it?
Chemotherapy can often alter the taste of foods. Familiar foods can taste different (called dysgeusia) or food flavours can taste less intense than normal (hypogeusia). Taste changes are usually temporary and disappear once your chemotherapy treatment is completed.

What can I do?
Certain foods may be more appealing than others; if foods are not appetizing they may need to be avoided for a period of time and then gradually re-introduced. Keeping your mouth fresh and clean and frequently rinsed may help.

Loss of Appetite

What is it?
Loss of appetite is a common side effect of chemotherapy. It may be a result of other symptoms, such as nausea, vomiting or taste alterations.

What can I do?
It may help to eat smaller, more frequent meals throughout the day. You may find this symptom improves if strong odours are avoided, if you avoid food preparation and if you eat cold food instead of hot. Even though food is unappetizing, it is still very important to stay hydrated by consuming fluids and trying to eat healthy foods to stay strong.

Hair Loss

What is it?
Hair loss, also called alopecia, is a common side effect of chemotherapy and can affect the hair of the scalp, eyebrows, eyelashes, arms, legs and pelvic region. It affects different people in different ways. Some people may lose all their hair and some may only experience thinning of their hair. Hair loss or thinning usually begins gradually, within two to three weeks of your first chemotherapy treatment. This can be a very distressing side effect for patients. However, not everyone experiences hair loss and most people have a normal amount of hair within six months after their final chemotherapy treatment.

What can I do?
Here are some tips for minimizing and coping with hair loss:

  • Pat your head dry rather than rubbing it vigorously with a towel.
  • Avoid hair dryers, curling or straightening irons.
  • Avoid dying your hair or using other chemicals.
  • Wear a hat when exposed to the sun as areas of hair loss are very susceptible to sun damage.
  • Consider wearing a hat, wig, scarf, turban or head wrap if it makes you feel better.

Decreased Blood Cell Production

What is it?
Blood cells, including red blood cells, white bloods cells and platelets, are continually being produced in the bone marrow. Because these cells are always dividing, they are also targeted by chemotherapy and, therefore, the number of all blood cells can be reduced. This is called myelosuppression. There are different types of myelosuppression depending on which blood cell is affected. They are anemia, neutropenia and thrombocytopenia.

Anemia is the term used to describe a decrease in the number of red blood cells, the oxygen carrying cells in the blood. Anemia can often cause patients to feel tired and lethargic and may require treatment if severe. Sometimes patients are prescribed injections to help stimulate the growth and production of red blood cells and decrease the side effects of anemia. Occasionally, blood transfusions are required for more severe anemia, especially when the bone marrow has been affected by the lymphoma.

Neutropenia occurs when there is a decrease in the number of neutrophils, a certain type of white blood cell. Neutrophils are very important for fighting infection. When there are too few, patients are more at risk for developing serious infections. If the neutropenia is severe, the chemotherapy may have to be delayed or the dosage reduced, as the risk of infection is serious. Sometimes patients with neutropenia are prescribed antibiotics to help fight off any possible infections. Injections may also be required on a routine basis to stimulate the growth and production of white blood cells and decrease the side effects of neutropenia.

Thrombocytopenia is the term used to describe a decrease in the number of platelets, cells that are very important for blood clotting. If platelet counts are low, a patient may experience increased bruising or excessive bleeding from cuts, nosebleeds and bleeding gums. Treatment may be needed if the thrombocytopenia is severe, with the usual treatment being a blood transfusion. Avoidance of blood-thinning medications (e.g., aspirin or anti-inflammatory drugs) may also be recommended.

What can I do?
The most important thing you can do is be alert for signs of myelosuppression. Signs of anemia include fatigue and lethargy. Signs of neutropenia include symptoms like fever, sore throat, rash, diarrhea, or redness, pain or swelling around a wound. Signs of thrombocytopenia include easy bruising or prolonged bleeding. If you notice these symptoms, inform your doctor immediately so appropriate action can be taken.

Fatigue

What is it?
Fatigue, or tiredness, is a common side effect of chemotherapy and usually goes away shortly after the treatment is complete. Severe fatigue can be a symptom of anemia and should be mentioned to your doctor. Fatigue is usually due to the strong chemotherapy medications and their effects on your body. It can also be due to the cumulative effects of many chemotherapy cycles, even those involving weaker chemotherapy drugs.

What can I do?
Some ideas about handling fatigue include:

  • Keeping a diary to help you keep track of the times of day when you feel most tired. This can help you plan activities according to how you are feeling, that is to say rest when you need to and use the time when you’re not tired to go about your daily activities;
  • Asking friends and family for help;
  • Exercising when you have the energy and as long as your doctor says it’s all right to do so. Yoga, stretching and short walks can increase your energy and improve your overall vitality. Start slowly and build up your endurance to a comfortable range;
  • Getting the rest and sleep you need while receiving chemotherapy. It may be important to take time off work and adjust your daily schedule to accommodate for rest and recuperation. Try not to rest more than necessary, as this can sometimes make you feel even more fatigued.

What are the Side Effects of Radiation Therapy?

Although the radiation treatments are painless, there may be some associated side effects. The side effects are usually limited to the area of the body receiving the radiation and may vary based on the targeted site. The most common side effects are listed here followed by helpful coping suggestions. 

Targeted Area Possible Side Effects
Head and neck (areas affected can include the scalp, mouth and throat)
  • Hair loss (on the scalp or anywhere the radiation is targeted)
  • Loss of appetite and taste
  • Dry mouth
  • Throat irritation
  • Skin reactions
Chest (areas affected can include the esophagus and breasts)
  • Difficulty swallowing
Abdomen
  • Nausea
  • Diarrhea

Hair Loss

What is it?
Hair loss from radiation is not like the general hair loss that occurs with chemotherapy. It involves only a patch of hair loss that occurs depending on the area of the body that receives the radiation. If the radiation was targeted at the head, a patch of hair loss may occur on the head. If the radiation was targeted at a specific lymph node in the groin area, there may be a loss of hair in the groin region. The hair loss is usually temporary; however, with high doses of radiation it may be permanent.

What can I do?
Here are some tips for minimizing and coping with hair loss:

  • Pat your hair dry rather than rubbing it vigorously with a towel.
  • Avoid hair dryers, curling or straightening irons.
  • Avoid dying your hair or using other chemicals.
  • Wear a hat when exposed to the sun, as areas of hair loss are very susceptible to sun damage.
  • Consider wearing a hat, wig, scarf, turban or head wrap if it makes you feel better.
  • You may require special shampoos or soaps. You can ask your radiation oncologist if these would be helpful for you.

Loss of Appetite and Taste

What is it?
Following radiation therapy you may find that foods you previously enjoyed no longer appeal to you. You may also not feel as hungry as you normally do.

What can I do?
It is very important to try to eat to keep your energy up and nutrition status optimal. It may help to eat smaller, more frequent meals throughout the day. You may find your appetite and taste improve if you can avoid strong odours and food preparation, and eat cold food instead of hot. Even though food is unappetizing, it is still very important to stay hydrated by consuming fluids, and trying to eat healthy foods to stay strong.

Dry Mouth and Throat Irritation

What is it?
After radiation therapy in the area of the mouth, saliva production may be decreased and patients may experience a dry mouth, also called xerostomia. Throat irritation may also occur from the decreased saliva or direct effects from radiation to that area.

What can I do?
Drink lots of fluids to keep your mouth as moist as possible. Saliva is important for fighting cavities so it may be necessary to use extra oral hygiene such as brushing your teeth after each meal and flossing (use caution with flossing if your blood cell counts are low). Your doctor may recommend you visit your dentist prior to receiving radiation treatments. Warm, gentle mouthwashes (non-alcohol based) may help refresh the area and decrease irritation. Eating foods that are more easily digested (soft foods or liquid dietary supplements) may be easier on your throat. Eating smaller meals and avoiding acidic foods like citrus fruits and citrus juices may also help.
For more information on this topic, please see this article.

Skin Reactions

What is it?
The area of skin that was exposed to the radiation may become red, irritated, itchy and flaky. Moist areas like the mouth may be more severely affected and may require treatment. It often looks and feels as though the area is sunburned and the skin may begin peeling. The skin reactions are usually short-lived and diminish over a few weeks.

What can I do?
It is important to protect these areas of skin from further damage. They should not be exposed to the sun, and should always be protected with sunscreen, even once the radiation therapy has finished. During treatment, your doctor may prescribe an alcohol-free, fragrance-free lotion or cream to apply to the affected area.

Difficulty Swallowing

What is it?
You may experience difficulty swallowing due to a dry mouth, or because the radiation has affected the esophagus which is involved in swallowing.

What can I do?
Staying hydrated and keeping the tissues in your mouth and throat as moist as possible may help. Eating softer, more digestible foods will cause less pain on swallowing and are easier to move through the digestive system. Healthy shakes and nutritious soups are good choices. Eating smaller meals more frequently may help ease the irritation.

Nausea

What is it?
Radiation therapy targeted towards the abdomen can sometimes cause nausea (the urge to vomit). The nausea may occur after the first radiation treatment.

What can I do?
Not eating in the few hours prior to your radiation treatment may help. Scheduling your treatments towards the end of the day may be helpful, so if you do feel nauseous, you can deal with it at home. Your doctor may prescribe an antiemetic (a drug that prevents vomiting) or antinauseant (a drug that prevents nausea) to be taken prior to the radiation treatment. If you experience nausea, the following are some ways to keep it under control:

  • Consume mostly liquids leading up to your radiation treatment, including soups such as broths or consommés (avoid milk-based soups).
  • Avoid foods that are too hot, cold, sweet or spicy, especially right before your treatment.
  • Eat smaller meals more frequently throughout the day instead of three large meals.
  • Get plenty of fresh air and try to avoid strong or unpleasant odours.
  • Take the medication prescribed by your doctor.
  • If you do experience vomiting, be sure to stay hydrated (see the tips in the Diarrhea section).

Diarrhea

What is it?
Frequent and watery bowel movements.

What can I do?
The most important consequence of diarrhea is dehydration (loss of body fluids). To avoid dehydration, the following tips may be useful:

  • Drink plenty of water throughout the day.
  • Avoid milk products as they may worsen your diarrhea.
  • Pay attention to the signs of dehydration: dry mouth or skin, decreased urination, and dizziness or lightheadedness upon standing.
  • Take the medications your doctor recommends for controlling diarrhea.

Are there long-term side effects with radiation therapy?
It is possible for radiation to cause long-term side effects. The following table outlines the possible consequences of radiation given to different areas of the body. It is important to discuss these risks with your doctor if you feel concerned.

Treatment Area Possible Long-Term Effect What You Can Do
Pelvis or groin Infertility Ensure that the testes/ovaries are shielded from radiation if they are not the target of the treatment. If you have not yet had children, talk to your doctor about the risks associated with having children after radiation therapy.
Chest and breasts Breast cancer Long-term breast cancer screening is very important.
Skin Skin cancer Long-term skin cancer screening is very important. Protect your skin from the sun by using sunscreen and minimizing exposure.
Neck Thyroid cancer Discuss the risks with your doctor and have your thyroid checked on a regular basis.