How to Manage Late Effects of Chemotherapy Drugs

Once a cancer patient’s treatments have ended, there is still a chance that he or she can experience side effects. Some side effects can continue after treatment or surface months or years after treatment. There is not a lot of concrete information that is known about cancer treatment side effects, but they can vary by treatment type and individual circumstances. 
 
Physicians aren’t sure why these effects occur late. Some doctors think the side effects may have been there during treatment, but they weren’t noticed because the body was counteracting them and after treatment the body no longer does this, thus they begin to emerge later. 
 
Side effects that are apparent during cancer treatment can continue to last months or years afterward. Most long-term effects reduce over time or completely disappear. An example of a long-term side effect is peripheral neuropathy. It can occur during chemotherapy treatment and continue months or years after treatment has been completed. 
 
What Chemotherapy Treatments Cause Late Side Effects? 
 
In general, chemotherapy treatments are more likely to cause late effects than other types of cancer treatments. Not all cancer patients may experience long-term or late effects and different chemotherapy drugs may cause various effects. 
 
Some of the following are long-term side effects from chemotherapy treatment: 
 
 

  • fatigue 
  • neuropathy 
  • chemobrain 
  • heart failure 
  • kidney failure 
  • infertility 
  • liver problems 
  • menopausal symptoms 

 
Some of the following are late side effects from chemotherapy treatment: 
 

  • cataracts 
  • osteoporosis 
  • chemobrain 
  • reduced lung capacity 
  • lung disease 
  • infertility 
  • liver problems 
  • second primary cancers 
     
     
     

More Information About Managing Chemotherapy Side Effects 
 
If cancer patients need more information, or have questions on how to manage chemotherapy side effects, they can contact The American Cancer Society at 1-800-ACS-2345, or read an online booklet, Understanding Chemotherapy: A Guide for Patients and their Families, at the following web address: http://www.cancer.org/docroot/ETO/ETO_1_5x_Guide_for_Patients_and_Families.asp 
 

Rash as a Chemo Side Effect

Chemotherapy drug treatment can cause a patient to experience rashes on the back, chest, arms, neck or face that may look like a rosacea or acne type condition. A patient usually experiences rash side effects that are mild to moderate. Rash side effects do come with an infection risk factor. In some cases if the rash is serious, the treatment drugs may be reduced, delayed or terminated.

Drugs That Cause Rash

Some of the medications that increase the likelihood of a rash are Tarceva (erlotinib) and Erbitux (cetuximab). They may cause an acne-like condition that arises in the second week of the cancer treatment, but may start to diminish by the fourth week of treatment. The rash goes away once the treatment has been completed.

These medications are directed toward the epidermal growth factor receptor (EGFR) and inflammation occurs that often causes an acne-like skin reaction.

Drug Treatments to Reduce Rash Side Effects

There are no real firm standards on what can be used to treat rashes for chemotherapy patients; however, following are some medications used to help reduce rash side effects during chemotherapy drug treatment:

– antihistamines such as Benadryl and Atarax to lessen itching
– topical corticosteroids
– antibiotics (oral or topical)
– Elidel being researched to control EGFR-related rash side effect

Why do the side effects occur in specific parts of the body?

Healthy cells in certain parts of the body are especially sensitive to chemotherapy drugs. The parts of the body that seem to be prone to side effects are the parts that have rapidly dividing cells. Chemotherapy drugs attack these cells and can result in various side effects based on the drug type, dose and route in which the patient receives the drugs.

The following cells are prone to side effects:

  • the bone marrow cells (which makes blood cells)
  • hair follicles cells
  • cells that line the mouth and throat
  • cells that line digestive system

Chemotherapy treatments are normally given in a group of sessions. The sessions are followed by a period of rest. The chemotherapy sessions kill the cancer cells and the rest periods allow the healthy cells to recover.

Constipation

Chemotherapy
drug treatment can cause a patient to experience constipation, or the
uncomfortable passage of hard, dry stools that are infrequent. Some
symptoms include bloating, cramping, increased gas and pain. About 50
percent of cancer patients experience constipation. Other side effects
can occur from this condition such as decreased appetite and nausea.

Drugs That Cause Constipation

Some of the medications that increase the incidence of constipation are
opioid pain medications and chemotherapy drugs such as vincristine and
vinblastine.

Other Causes of Constipation

Other than medications there are other factor that can lead to an increase in the likelihood that a patient experiences constipation such as depression, decreased fluid or food intake, dehydration, low fiber diet and lack of physical activity.   

Drug Treatments to Reduce Constipation 

Following are some medications that may help reduce constipation during chemotherapy treatments:

  • Psyllium (Metamucil) 
    – Docusate sodium (Colace)   
    Bisacodyl (Dulcolax)  
    – Sorbitol and sodium phosphate (Fleet’s enema) 
    – Glycerin suppository 
    – Magnesium hydroxide (Milk of Magnesia)  
    Senna (Senokot)  
    – Lactulose (Chronulac)  
    – Magnesium citrate 

Non-Drug Treatments to Reduce Constipation 

Following are some non-drug methods to help reduce the incidence of constipation during chemotherapy drug treatment: 

  • stay physically active
  • try to drink at least 3 quarts of fluids per day
  • try to eat high-fiber foods
  • patients to tell their doctor if they don’t have bowel movement for more than three days

Diarrhea

Chemotherapy drug treatment can cause a patient to experience diarrhea, or the passing of an increased amount of a watery or loose stool multiple times throughout the day. Some symptoms include bloating, cramping, increased gas and pain. About 3 out 4 cancer patients experience diarrhea during chemotherapy treatment due to the attack on the cells in the digestive tract.

Drugs That Cause Diarrhea 

Some of the medications that increase the incidence of diarrhea are
dactinomycin, doxorubicin, docetaxel, methotrexate, irinotecan,
5-fluorouracil, antibiotics or antacids.

Also the dose of the chemotherapy drug can play a role in whether or not a patient experiences diarrhea.

Diarrhea
can lead to dehydration and is a common side effect of irinotecan
(CPT-11). Patient’s should tell a physician when diarrhea occurs and
follow his or her instructions to stop the condition.

Other Causes of Diarrhea

Other than medications there are other factors that can lead to an increase in the likelihood that a cancer patient experiences diarrhea such as
stress, anxiety, food allergies, when a patient receives radiation and
chemotherapy simultaneously, stomach tumor, nutritional supplements and
the length of treatment.

Non-Drug Treatments to Reduce Diarrhea

Following are some non-drug methods to help reduce the incidence of diarrhea during chemotherapy drug treatment


  •  
    – stay physically active 
    – try to drink at least 8-10 glasses of fluids per day (i.e. water, Gatorade, broth) 
    – try to eat small portions of low-fiber foods frequently (i.e. banana, rice, bread, chicken) 
    – avoid greasy, fatty, fried foods 
    – avoid vegetables and fruits 
    – limit caffeine beverages and extremely hot or cold beverages 
    – avoid whole grain bread, cereal, nuts, popcorn 
    – avoid gas-forming foods and beverages 
    – avoid alcohol, lactose-containing products and supplements

Over-the-Counter Medications to Reduce Diarrhea

Following are some over-the-counter medications to help reduce the incidence of diarrhea during chemotherapy drug treatment: 

  • Kaopectate®II caplets 
    Maalox®anti-Diarrheal caplets  
    Loperamide (Imodium®)  
    Pepto® Diarrhea control (follow instructions on container)

Fatigue as a side effect

Chemotherapy drug treatments can be effective, but they also seem to be linked to intense fatigue. Drugs that often cause cancer-related fatigue are vinblastine, cisplatin and vincristine.

The severity of fatigue may vary by individual, but almost 90 percent of cancer patients experience some level of fatigue related to cancer treatment at some time during therapy. It is also known that the symptoms from fatigue can last for months or years after cancer treatment.

Specifically, fatigue can be caused by cancer-related anemia or low thyroid function and can intensify with emotional distress or depression related to the cancer treatment. A patient with fatigue may feel weak, forgetful, have decreased energy level and an inability to concentrate.

Drug Treatments to Reduce Fatigue

Physicians treat cancer patients that suffer from fatigue in a similar way to patients with anemia. Doctors use drugs that produce hormone and stimulants such as Ritalin (methylphenidate) and Provigil (modafinil).

Other Treatments to Reduce Fatigue

None-drug treatments such as exercise, diet and conserving energy have been shown to reduce fatigue.

Exercise

Doctors put their patients on a low-intensity exercise regimen to avoid the loss of too much muscle mass that can lead to fatigue more easily than someone that does some sort of physical activity. Too much high-intensity exercise is not good for cancer patients since it can put the immune system at risk.

Diet

Cancer patients can monitor their diet to help reduce fatigue. If a patient doesn’t maintain the proper nutrition by eating the right foods, this will contribute to fatigue. It is recommended that a cancer patient gets at least 15 calories per pound of his or her body weight. Proper amounts of protein are also important to help rebuild and repair body tissue. The recommended amounts of protein are 0.5 to 0.6 grams for every pound of body weight. Patients should have a minimum of 64 ounces of fluids per day and limit their intake of alcoholic and caffeine beverages. It is recommended to supplement their diet with a multivitamin that gives them 100% of the recommended daily nutrients.

Conserve energy

Cancer patients should organize their tasks ahead of time and try to schedule rest periods to help save energy throughout their day. The following are some recommendations to conserve energy:

– Take time in the day to rest
– Take multiple short naps or breaks instead of one long break
– Save energy for important tasks
– Get help to delegate some tasks
– Moderate pace is better than rushing through tasks

Oral Mucositis – Sores in Mouth and Throat

Some chemotherapy drugs can cause sores in the mouth or throat because they inhibit the replacement of the healthy cells. The condition that causes sores in the mouth is known as stomatitis, and a comparable condition in the throat is known as pharyngitis.  

The lining of the mouth starts to become pale and dry. As time goes on, the mouth and throat may become red, sore and inflamed. The patient may have trouble eating, talking or swallowing. Eventually, the condition can lead to painful, bleeding ulcers and possibly infection. This condition normally develops approximately 5 to 14 days after chemotherapy treatment has taken place. These conditions eventually heal once chemotherapy treatment has ended. 
 
It has been determined that up to 75 percent of patients who receive high-does chemotherapy get oral mucositis and approximately 40 percent of patients that receive standard-dose chemotherapy experience this side effect. 

  
Drugs That Cause Oral Mucositis 
 
Some chemotherapy drugs such as methotrexate and 5-FU have shown to cause a higher incidence of oral mucositis than some others. If the patient is treated early, it can lessen the severity of the symptoms. 
 
Treatments to Reduce and Relieve Incidence of Oral Mucositis 
 
There are some common none-drug treatments to help reduce the severity of oral mucositis. 

Following are some steps that can be taken to help the healing process: 

– Keep the mouth clean and moist 
– Brush teeth with a soft toothbrush or swab 
– Stay away from mouthwashes; rinse with salt or baking soda solutions 
– Stay away from foods and juices that are acidic 

There are some medications that have been recommended and administered to cancer patients to help alleviate pain from oral mucositis. They include the following: 
 
– Tylenol liquid (acetaminophen) – helps relieve pain but doesn’t heal sores 
– Kepivance (palifermin) – this drug is used for severe cases of oral mucositis in patients with  
  blood cancers 
– Gelclair (hyaluronate)- relieves pain by creating a protective barrier and coating the oral  
  mucosa 
– Saforis (glutamine) – a new drug known to be effective in preventing and treating oral mucositis 

Religion and Spirituality

Some patients may take solace in their religious or spiritual beliefs after receiving their diagnosis.  Patients can often experience an outlet of their pent-up emotions through prayer and meditation.  Many studies have shown that patients who employ such practices have better psychological outlooks during treatment than those who do not.  Also, many clergymen have been trained in counseling techniques similar to those of mental health professionals.  For those patients with religious backgrounds, such spiritual guidance can be very helpful both to them and to their families.  

Also, activities such as meditation, reflection and journaling about the experience can alleviate much of the emotional turmoil in a patient’s mind.  Simple meditation can clear the mind of distracting or negative thoughts.  Slow, steady breathing can improve mental functions and regulate heart rate.  Reflection on one’s life and accomplishments can show the patient that their life is worthwhile and improve their outlook during the most stressful stages of therapy.  Writing a journal about the process can also help the patient work through their emotions in a constructive manner.  Each of these methods is useful in developing a strong mental attitude and aiding in physical healing.

Recovery and Recurrence 

Patients who complete their treatment regimen and receive a cancer-free prognosis may feel as if a massive burden has been lifted from their backs.  In the most literal sense, they have a new lease on life.  While the most arduous part of the recovery process may be over, the work to maintain their health truly begins.  The staff at the Mayo Clinic recommends that patients who have finished treatment continue to take part in all of the activities they started during their recovery.  These include staying with a healthy diet, regular exercise and other healthy habits such as avoiding tobacco and alcohol.

During follow-up exams, some cancers can show signs of recurring at or near the same location in the body where the first tumors appeared.  Many patients will feel the same type of distress and anxiety that they experienced during their initial diagnosis.  Others may start to believe that the time, effort and money spent on combating the initial cancer has been wasted; they may not feel strong enough to go through the same battle all over again. 

One of the advantages that patients who receive a diagnosis of a recurrence can use is that they are much more prepared than they were the first time.  They also have access to many more educational, emotional and social resources and understand the process much better than they did after their initial diagnosis.  Also, in most cases, the treatment schedule will be much easier; patients may experience less discomfort and doctors will be able to treat the patient more effectively and with less “trial and error”. 

A patient who experiences a cancer diagnosis understands it as a life-changing event, both for themselves and everyone in their life.  While the disease and treatment can affect every aspect of daily life, many tools exist today to help deal with the impact.  In order to cope with this trying situation, patients should start asking questions without fear and anxiety.  From there, they should take the information they’ve gathered to form plans and organize details to smooth out the long and arduous process.  Numerous health care professionals and cancer survivors understand that, when fear wins, the patient loses. 

Side Effects of Treatment

Another major issue that patients deal with on a consistent basis during treatment is the side effects of the various remedies. Radiation therapy can cause hair loss and digestive problems. Chemotherapy sessions can leave a patient feeling lethargic and depressed. Prescription medications can cause mood fluctuations and disruptions in sleep patterns. Some other side effects that patients could encounter include:

  • Constipation

  • Diarrhea

  • Fatigue

  • Incontinence

  • Low White Blood Cell Count/Weakened Immune System

  • Mouth Sores

  • Nail and Skin Discoloration

  • Nausea

  • Nerve Damage

  • Sexual Inability

  • Shortness of Breath

  • Vomiting

In fact, many patients may fear the treatment side effects more than the damage done by the disease itself. Such fears may make patients hesitant to accept traditional treatment methods. Doctors often prescribe additional medications for the purpose of managing these effects (e.g. opioids for pain, antidepressants for mood swings, antibiotics for infection)

Nutrition and Health

Many patients undergoing cancer treatment often deal with a loss of energy and appetite during the process. Other side effects include weight loss and intestinal or digestive problems. Everyone involved in the patient’s treatment schedule should recommend that the patient maintain a healthy, nutritious diet. Such a diet will give the patient the energy that they will need during treatment and lessen the impact of severe weight loss.

Nutritional balance in a patient’s diet in these stages is critical to the recovery process. Many patients may read or hear about someone promoting an “anti-cancer miracle diet” that promises to treat, or even remove, the cancer without the harmful side effects of traditional therapies. However, most of these fad diets emphasize taking in massive quantities of one type of food, drink or vitamin supplement at the expense of any others. If the patient has such concerns, they should ask their doctor to recommend a nutritionist. These specialists can create and, in many cases, prepare healthy recipes that will meet the patient’s special nutritional needs.

Health care professionals will also recommend that patients refrain from tobacco and alcohol consumption, foods loaded with fats and sugars, and activities that disrupt healthy sleeping and eating patterns. Regular, non-strenuous exercise activities such as walking or bicycling should also help patients grow healthier both physically and psychologically. Simple exercises can improve blood flow, regulate breathing and increase efficacy of treatments.

Social Interaction

Patients often feel some trepidation about broaching the subject of their cancer diagnosis and treatment to their friends, bosses and co-workers. Although they hope that this new fact would not change their friends’ view of them, such is not often the case. Some friends may withdraw out of awkwardness, unsure as to how best to respond. Others may back away out of some innate fear of contagion. Still others may be overly inquisitive or obsequious, treating the patient as a fragile china doll and fearful that they may break. Employers may make plans to alter or lessen patients’ workloads, causing resentment from co-workers. For example, employers fearful of clients’ reactions to the patient’s diagnosis may move patients whose primary duties involve face-to-face interactions with clients away from such direct contact positions.

Just as is the case in dealing with the family, the best avenue for dealing with other people is to be honest and open in answering all questions. Patients should express their gratitude for those who express their sympathy and understanding. They should also be prepared to answer the concerns of those who may feel that the disease will impact their relationships, either personally or professionally. Patients can also take this opportunity to address any issues their employers may have in terms of both their ability and availability to carry out their duties during treatment.

Support groups also provide excellent avenues for a patient to have a level of social interaction. These groups can give the patient something that no other group involved in the process can: the voice of experience. For patients at the beginning of their treatment regimen, they can chat with (either in person or online) other group members who have moved into more advanced phases of treatment and can let them know what to expect as their treatment progresses. Such groups can pass advice, share stories and reinforce the idea that the patient is not alone in their process. Groups can serve the purpose of both emotional support and educational resource and many are tailored to the patient’s age, background and specific form of the disease.

The journal Social Science and Medicine published a study that showed a statistical link between social support and recovery:

“Coping was assessed half a year after surgery, while benefit finding was examined 12 months post-surgery. Correlational and path analyses showed a link between personal resources (self-efficacy) as well as social resources (received social support) and benefit finding. The effect of self-efficacy disappeared when coping was specified as a mediator between the resources and benefit finding. Social support retained a direct effect on benefit finding. The results emphasize the predictive quality of resources for recovery and adjustment after surgery and the mediating role of coping.“

Whether it is through family, friends or peer groups, patients should realize that they are not alone in their efforts. Any constructive social outlet can help patients understand that they have resources to communicate their ideas in spite of the disease. As patients at one highly esteemed cancer center say in their television commercial, “I have cancer, but it doesn’t have me.”

Emotional Health

After many of the more pressing issues have been resolved, some patients still deal with serious emotional issues during the various treatment phases. Depression, anger, anxiety and frustration often occur with patients as they carry out the long and arduous process. For those patients with a previous history of substance abuse, the impact of the diagnosis may lead to a relapse into addiction as a means of escape. With the frequent need for pain medication that most treatment regimens prescribe, such patients could do more damage to themselves by abusing the drugs that they need to manage their condition.

The emotional aspect of the treatment schedule is almost as important as treating the disease itself. Oncologists, nurses, mental health workers and family members can all participate in this portion of the process. Family members and friends can be observant of the patient’s behavior and watch for any signs of mood changes or alterations in attitude. The patient may be depressed about a lack of progress or frustrated about attending treatment sessions, so the family should do what they can to encourage a positive outlook during this trying time. Health care professionals involved in the treatment routine should also keep an eye on the patient’s emotional barometer. Mental health care specialists can help the patient work through their tumultuous emotional issues and give them the best opportunity to complete their treatment successfully.

Another source of anxiety that patients encounter is the changes in their appearance that often arise from their treatment. Weight loss, hair loss and skin conditions often appear as side effects of radiation treatments and chemotherapy. In the case of breast cancer, patients may require a mastectomy (removal of the breast tissue). These alterations can significantly affect the patient’s self-esteem and self-image; the patient may not feel as attractive, young or vital as they did pre-diagnosis.

Many hospitals and specialty stores carry wigs, makeup and prosthetics to help patients deal with the changes in their appearance. Some cancer patients use these changes as an opportunity to experiment with their self-image. A patient that started treatment with long, blond hair, for example, may want to try a brunette bob wig. Another may use different shades of foundation and lipstick for a new look. Such activities can serve as a distraction from the more painful effects of treatment and allow the patient to forget about their condition for a brief moment.