Chemotherapy

Chemotherapy may be used for three purposes:

• To prevent or postpone cancer from coming back after surgery or radiation have removed all known cancer, by attempting to kill any cancer cells that have separated from the original tumor. (Known as adjuvant therapy.)

• To shrink large cancers, for easier surgery. (Known as neo-adjuvant therapy.)

• To treat metastatic disease, where the cancer cells have shown up in parts of the body other than the primary site of the cancer.

Chemotherapy may be delivered intravenously, in pill form, or both. It can last from a few minutes to over an hour. To alleviate anxiety, you may bring music, or ask a friend or family member to stay with you during treatment.

Surgeons also perform port-a-caths; these are devices inserted into the vein with an opening to the skin for chemotherapy drugs. These ports also can be used to take blood and administer fluids, and are placed on an outpatient basis. They can be removed once treatment is finished.

Chemotherapy is typically most effective when two or more drugs are used together. These can cause a variety of side effects, depending on the drug or drug combinations and the dose.

A typical course of chemotherapy can last up to six months. It's given in cycles, which are followed by a recovery period. Cycles are two to four weeks, but some courses can involve weekly treatment.

In adjuvant and neo-adjuvant therapies, chemotherapy is usually given in combinations of two or more drugs. Chemotherapy given with one drug at a time (known as single agent) can be useful in treating metastatic cancer.

If you do not experience side effects, this is not a sign that the chemotherapy isn't working. If you are receiving treatment for metastatic disease, your doctor will monitor your progress through blood tests, scans and/or x-rays.

If you are undergoing adjuvant chemotherapy, your doctor will evaluate your progress. It will be measured through physical exams and other tests as needed.

Nausea/vomiting that occurs with chemotherapy can be caused be the chemotherapy drugs or the anticipation of receiving chemotherapy drugs. There are several anti-nausea/anti-anxiety medications that can help prevent nausea/vomiting. Relaxation techniques or Reiki may also be helpful. Anti-nausea medications can work differently for different people. If the prescribed regimen does not work well for you, please call your doctor or nurse, as other options are available.

Steps to Take:

• Prevent vomiting by preventing nausea. Take anti-nausea medications as prescribed, following the schedule set by your nurse.
• Eat smaller, more frequent meals (four to six per day).
• Avoid fried, fatty and spicy foods the day of chemotherapy and the three days following or until you are able to eat without taking anti-nausea medications.
• Caffeine, acidic beverages/foods (for example, orange juice or tomato sauce) may upset to your stomach.
• Dehydration can make you feel nauseated. Drink 8 to 12 glasses of fluids per day. Try popsicles or ice chips as well.
• Try relaxation techniques before or during chemotherapy.
• If you feel sick, try spending time in fresh air, chatting with friends or family, watching TV or listening to music.

When to Call Your Doctor or Nurse

Call your doctor or nurse if you are unable to drink or keep fluids down for 12 hours, or have decreased urine output or dark urine, as these could be signs of dehydration.

Chemotherapy affects the fast growing cells that line your mouth, lips and throat. You will be asked to check your mouth, lips, gums and tongue.

What to Check:

• Check your mouth, lips, gums, teeth and tongue daily for sores, white spots, ulcers, redness, swelling, tenderness, or for any difficulty with swallowing.
• Avoid routine dental cleanings during chemotherapy. If you need emergency dental treatment, please discuss with your doctor or nurse before seeking dental care.
• Try to notify your dentist two weeks prior to starting chemotherapy. Your dentist may want to do a dental exam and recommend toothpaste or a mouthwash for you to use.
• Keep your mouth moist. Talk to your nurse about saliva substitutes.
• Brush your teeth with a soft toothbrush. If you normally floss, floss gently. If spontaneous bleeding occurs stop flossing and call a nurse.
• Do not use a mouthwash that has alcohol. Try using 1/8 teaspoon salt and/or 1/4 teaspoon baking soda in one cup of warm water after meals and at bedtime. If you have dentures or partials, remove them and clean separately.
• If you wear dentures, please make sure they fit well and you inspect your gums. Do not use dentures if you experience any discomfort.
• Apply lip moisturizer often.

When to Call Your Doctor or Nurse

Call your doctor or nurse if you have any difficulty swallowing or experience unusual symptoms. Your doctor may need to prescribe medications to treat or prevent mouth infection.

During your treatments you may experience fatigue. Fatigue can be caused by the type of chemotherapy you receive, stress, anxiety, depression, pain, interrupted sleep, work load, frequent trips to your appointments or trying to manage the responsibilities of daily life.

How to lessen and treat fatigue:

• Allow for periods of rest and activity.
• Studies show exercise can ease fatigue; try short walks or riding an exercise bike.
• Plan to do your most important task of the day first.
• Organize time to avoid rushing (for example, laying out clothes the night before).
• Prepare meals while sitting down and keep frequently used items easily accessible.
• If you're working, plan your day to take advantage of your peak energy times.
• Plan a work schedule that's best suited for your needs.
• Let others help. For example, let friends or family members help with chores, shopping or cooking.

When to Call Your Doctor or Nurse

Call  if you experience dizziness, shortness of breath, a change in activity level, severe tiredness, depression or anxiety.

During chemotherapy some or all of your hair may fall out. Hair loss, also known as alopecia, can happen anywhere on your body. Some types of chemotherapy can affect the cells that cause hair growth. Hair loss can begin as soon as two to three weeks after the start of chemotherapy. Your scalp may be tender. Hair loss may happen a little at a time or in clumps.

Most of the time, your hair will grow back two to three months after chemotherapy is over. Your hair may start to grow back even while you are getting chemotherapy. Your hair may be very fine when it starts growing back. Your new hair may also change in color or texture.

What to do before hair loss:

• Cut your hair short or shave your head. This can help reduce scalp tenderness and may also help you to adjust to your hair loss. If you shave your head, use an electric shaver and not a razor.
• If you plan to buy a wig, try to do so before you lose your hair. This will allow you to match the wig to your hair color and have it styled to look like your own hair. Make sure to choose a wig that feels comfortable on your scalp.
• Ask your nurse or social worker if your insurance covers the purchase of a wig. Free wigs and turbans are available through the American Cancer Association representative at The Miriam Hospital's clinic. The clinic also has a list of wig stores in Rhode Island.
• Be gentle when washing your hair. Use a mild shampoo or baby shampoo and pat dry with a soft towel.
• Do not use items that could hurt your scalp, like hair dryers, curling irons, hair bands and clips, hairspray, hair dye, or products to perm or relax your hair.

What to do after hair loss:

• Protect your scalp by wearing a hat, turban or scarf, especially when you are outside. Always apply sunscreen to protect your scalp. Avoid extreme temperatures.
• Try sleeping on a satin pillowcase. Satin is smooth and may feel more comfortable.

The fast growing cells in your skin and nails may experience changes during chemotherapy treatments. It is very important to notify you doctor or nurse if you experience any changes in your skin or nails.

What to do:

• Use mild, moisturizing creams and sunscreens.
• Notify your doctor or nurse if you experience a rash, redness, peeling, itching, burning, numbness, blistering, pain, acne from rash, dryness to your skin or swelling of the hands or feet.
• Never treat skin problems yourself consulting your doctor or nurse. For example, some rashes look like acne, but are not treated like acne.
• Avoid perfume, cologne or aftershave lotion that contains alcohol.
• Avoid hot, long baths. Try sponges or showers if your skin is irritated. Pat your skin dry, never rub.
• Maintain good nail care. Keep nails short. They may become brittle and break. If your nails are professionally manicured, bring your own tools.

When to Call Your Doctor or Nurse

Some skin changes can signal an allergic reaction. Please notify your doctor or nurse if you have severe itching or rashes. Please seek emergency care if you have wheezing or difficulty breathing. These are signs of an allergic reaction.

Reducing pain is a very important goal for our doctors and nurses.

Sometimes pain can be caused by the cancer itself or by the chemotherapy. Your doctor or primary nurse will address your pain needs at each visit.

What to do:

• Keep a pain diary. Write when, where, and how long your pain lasts. Write if anything makes your pain worse or better, if you took any medicines and, if so, how many and how often.
• It is important to take your pain medication as your doctor prescribes.
• Do not skip doses of your pain medicine. If you wait too long, it can be difficult to get your pain under control.
• Some pain medicines require a written prescription from our doctor, and a 24-hour notice before filling at your pharmacy. Our nurses need at least one to two days to obtain a new, written pain prescription.

When to call your doctor or nurse:

• If you experience new pain, an increase in pain or if your pain does not subside after taking medication.
• If you have pain (burning, stabbing, shooting, pressure, aching, sharp, dull, throbbing, or any other pain symptoms).
• If you experience constipation related to your pain medicine. You should not skip pain medicine to prevent constipation, which may be treated with laxatives and stool softeners.

If you are unable to notify your doctor or nurse about your pain, please have your contact person call for you.

Red blood cells carry oxygen throughout the body. Some types of chemotherapy decrease the body's ability to make red blood cells to carry the oxygen that your body needs. Your doctor will check your blood cell count throughout your chemotherapy as needed.

What to do:

• Get plenty of rest. Take short naps as needed.
• Limit your activities. Prioritize your activities and do only those that are most important.
• Accept help from family and friends when needed.
• Eat a well-balanced diet.
• Stand up slowly. Dizziness can occur if you stand up too fast.

Call your doctor or nurse if you have (one or more):

• An unusual or significant change in your activity level
• Dizziness
• Shortness of breath
• Fatigue/severe tiredness
• Racing or pounding heartbeat
• Paleness
• Feeling cold
• Weakness 

Platelets are cells that help your blood clot when you bleed. Some types of chemotherapy make it harder for your body to make platelets. A low platelet count is called thrombocytopenia. Your doctor will check your platelet count throughout your chemotherapy treatment.

Preventive Steps to Take:

• Use a soft toothbrush.
• Blow your nose gently.
• Be careful when using scissors, knives or sharp objects.
• Use an electric shaver.
• Wear shoes all the time to protect your feet.
• Avoid constipation.
• Do not use dental floss or toothpicks.
• Avoid contact sports or activities that could cause injury.
• Do not use enemas, suppositories, tampons or rectal thermometers.
• Do not wear tight clothes with tight collars, wrists or waistbands.
• Check with your doctor or nurse before taking vitamins, herbs, minerals, dietary supplements, aspirin or other over-the-counter medications. Some of these medications may increase your risk of bleeding.

If you have external bleeding, apply pressure to any cuts until the bleeding stops.

When to Call Your Doctor or Nurse

Call your doctor or nurse if your urine is pink or red, if you have black or bloody stools, have unexpected bruising or bleeding, bleeding from your nose or gums, or a rash of tiny red or purple dots.

While you're receiving chemotherapy, watch for signs of infection. Some kinds of chemotherapy lower the number of white blood cells, which fight infection in your body.

What to do:

• Have your blood work done as soon as it's ordered.
• Monitor your temperature as instructed by your doctor or nurse.
• Please call if you have a fever over 100 degrees. Do not take any medicine unless instructed to do so by your doctor.
• Wash your hands often with soap and water.
• Always wash your hands after touching pets.
• Use sanitizing wipes to clean surfaces before touching things such as grocery carts handles.
• Avoid people who are sick, and crowds.
• Check your body for signs of infection, paying close attention to your eyes, nose, mouth, skin, genital and rectal areas.
• Clean cuts right away and apply antiseptic. Be careful not to cut or nick yourself. Do not squeeze or scratch pimples.
• Wear protective gloves when doing household activities like gardening or washing dishes.
• Do not use enemas or suppositories unless instructed by your doctor or nurse.

Please call your doctor or nurse right away if you think you have an infection, or have any of the following symptoms:

• Redness
• Swelling
• Chills
• Cough
• Stiff neck
• Headache
• Eye drainage
• Sinus pain or pressure
• Painful or frequent voiding
• Fever
• Any other unusual symptom 

Some types of chemotherapy can damage the cells of your peripheral nerves. This is called peripheral neuropathy. Most problems get better within a year after chemotherapy, but some may last longer. Your doctor or nurse will monitor for signs of neuropathy.

What to do:

• Inform your doctor if you experience any of the symptoms listed below before you start chemotherapy. Some people with health conditions like diabetes have preexisting neuropathies.
• Be careful when handling sharp objects such as scissors or knives.
• Always wear good supportive shoes/sneakers. Do not go barefoot. If you step on an object, you may not feel it if you have numbness or decreased sensation in your feet.
• Be careful not to burn or cut yourself. Wear potholders when handling hot foods and wear gloves when washing dishes or gardening.
• Avoid bath water that is too hot or cold.
• Inspect your skin, especially your arms, fingers, legs and toes, for cuts, abrasions and burns.
• Your doctor can prescribe pain medicines for your peripheral neuropathy. Sometimes physical and occupational therapy can be helpful.

Call your doctor or nurse if you experience any of these symptoms:

• You experience tingling, burning, weakness, or numbness in your hands or feet.
• Feel colder than normal. 
• Feel clumsy.
• Lose your balance.
• Experience shaking or trembling.
• Have hearing loss.
• Have trouble picking up objects or buttoning your clothes. 
• Experience memory problems.
• Suffer from constipation or heartburn.
• Have any other unusual symptoms.

Please call right away if you notice any symptoms. It is important to treat these problems as soon as possible. Sometimes your doctor will adjust the dose of your chemotherapy or suspend treatment to prevent neuropathy from getting worse or becoming permanent.

Menopause is a natural life stage for a woman that begins with the final menstrual cycle, when the ovaries stop producing eggs.

Chemotherapy can cause irregular or missed menstrual periods or may damage the ovaries, resulting in menopausal symptoms or menopause.

Chemotherapy can trigger menopause at any time, including after your treatment has ended.

There's no way to determine exactly how and when chemotherapy and other cancer treatments will affect your menstrual cycle; however, menopause rarely occurs as a sudden response.

Cancer and some treatments for cancer may cause you to lose your appetite. However you need to continue to nourish your body to avoid malnutrition and weight loss. Your body requires nutrients from food to repair cells and to build new tissue while undergoing cancer treatment.

What to do:

• Ask family and friends to help you shop for food if you tire easily.
• Keep a supply of foods that you like and require minimal effort to prepare. Cheese sticks, cereal, nuts, trail mix, fruit, boxed juices and frozen entrees are some examples.
• Ask family and friends to help you make large batches of nutritious meals that you can freeze for later use. This makes it easier to have healthy meals on days when you have less energy.
• Do not try to lose weight during treatment. Your body needs nourishment to recover from the treatment. If you weigh more than your ideal weight, you may lose weight once you feel better.
• Good calorie sources are whole, natural foods dense with nutrients.
• As a general rule, avoid large doses of vitamins and minerals. Check with your doctor or nurse before taking any medicines, vitamins, minerals or herbs not prescribed by a doctor during your cancer treatment. You may need to avoid some of these.

You may ask your doctor or nurse for a referral to a registered dietitian. Our cancer center's dietitians are board certified in oncology nutrition. The dietitian will be able to individualize your nutrition plan, accounting for pre-existing conditions such as diabetes. The services of a dietitian may be especially helpful if you have gastrointestinal, lung, head or neck cancer; or if you have a feeding tube.

Decrease your risk of food-borne illnesses by following food safety guidelines.

To ensure your food is safe to eat:

• Thoroughly wash your hands and clean all preparation and cooking surfaces before and after fixing meals and snacks.
• Wash all raw fruits and vegetables. Other raw foods like seafood, including sushi and raw shellfish, should be avoided.
• Do not eat rare meat, especially ground beef. Do not eat chicken or turkey that has any pink areas.
• Use a meat thermometer to determine whether or not meat has reached the necessary bacteria-killing temperature.
• Use a separate cutting board for working with meat and another for working with fruits and vegetables. It is best to label the boards so that they are only used for one or the other.
• Throw out leftovers that are more than three days old. When in doubt, discard any food that does not look or smell right. 

Cancer and some of the treatments for cancer may cause you to lose your appetite. However, you need to nourish your body to avoid malnutrition and weight loss.

Try to plan ahead for times when you might lose your appetite by having foods readily available that you typically enjoy and that are easy to digest. Not eating will tire you and can harm your health.

What to do:

• Eat in a quiet, relaxed place. Dine with people you enjoy. Pleasant music or special dinnerware and table linens may make eating more appealing.
• Different colors, textures, and flavors may make foods more appetizing.
• Your sense of taste may change. If a food does not taste good to you, try seasoning it with lemon or lime juice, salt, pepper, herbs, sauces, marinades, mild spices or other flavorings. You may need to season food more than usual if your sense of taste has changed.
• Be flexible about when and what you can eat. Eat foods that appeal to you at that moment. Foods that do or do not appeal to you may change over the course of your treatment. Try to keep an open mind; be adventurous! Meals can be anything you like. You may enjoy having breakfast foods for lunch or dinner and leftovers for breakfast.
• You may want to eat small meals throughout the day rather than eating at specific meal times. Try eating small meals four to six times per day.
• Early morning is the best time to eat. Eating a large meal early in the day, however, may lead to nausea. Try eating a small meal, assess how you feel, and then eat another small meal.
• Keep lots of easy to eat food on hand for snacks. Milkshakes, chilled canned fruit, ice bars, and breakfast drinks can be eaten slowly between meals.
• There may be days when you eat very little or not at all. To avoid dehydration, remember to continue drinking fluids even if you are not eating. Try to eat more on the days you feel better to make up for calories missed on the days with decreased appetite.

Moderate weight loss is a normal and common side effect of cancer treatment. A rapid weight loss, however, is a concern. Rapid weight loss is defined as an unintentional weight loss of more than two pounds in a week when you are eating normally.

People who stay at or near their normal weight during treatment tend to recover faster after treatment. If you are overweight at the start of your treatment, a slight weight loss is not a concern.

Concentrate on eating healthy foods during treatment to maximize your nutrition. Limit foods like desserts and salty snacks; these will add calories without providing the nutrients you need.

You don't have to be strict about fats in your diet during cancer treatment. A diet that is moderate in fat and moderate in carbohydrates is best for general health.

Nuts are a form of healthy fat. You can add nuts to your breakfast cereal or salads, or use them for a snack. Consider choosing dry nuts because salted or oiled nuts are easy to overeat.

If you lose weight during treatments, it means you need more calories in your diet. If you don't know your ideal weight, ask your dietitian to help determine a healthy body weight for you.

Your sense of taste may change throughout treatment; some foods may not taste as you expect. Red meats may taste bitter, for example. If this is the case, poultry, fish, eggs, dairy products or soy products may be more palatable alternative sources of protein. Nuts, peanut butter and cooked dried beans are also good sources of protein that may taste better to you.

Tips to manage taste and smell changes:

• Try commercial marinades, fruit juices or salad dressings to marinate meat. Herbs and steak sauces may make meat, fish and poultry taste better.
• Cook vegetables in extra virgin olive oil to make them taste better. Of the cooking oils, extra virgin olive oil is the healthiest choice. In addition to containing fats good for your body, being easier to digest, and making your food taste better, extra virgin olive oil helps increase your body's absorption of the carotenoids found in dark vegetables. Carotenoids are what give deep color to broccoli, carrots, spinach, tomatoes and other fruits and vegetables. A number of studies suggest that carotenoids are powerful cancer fighters.
• If your mouth is not sore, try a bit of salsa, hot sauce, soy sauce, pepper sauce or Asian spices to perk up main dishes.
• If sweet foods and beverages taste metallic or too bland, try salty or herb-seasoned foods, such as tomato juice, bouillon, soups, snack chips or deli salads.
• If sour or bitter foods taste too strong, try foods that are bland or only mildly seasoned. You may need to trade off between bland and spicier foods if your sense of taste changes a lot.
• To help clear your taste buds before eating, rinse your mouth with a solution of one cup warm water, 1/2 teaspoon of salt and 1/2 tablespoon baking soda. Do not use mouth rinses that contain alcohol.

To increase your caloric intake, it is better to increase foods that are higher in nutrients, like nuts and olive oil, than to add calories from desserts.

Here are some foods that will add calories to your diet that are not harmful to your health:

• Extra virgin olive oil can be used to cook vegetables, prepare foods in general, as a salad dressing, or to dip bread.
• Olives in salads, casseroles, and main dishes.
• Nut or nut butters, for example, natural peanut butter, can be spread on sandwiches, crackers, as well as on bananas, apples or other fruit.
• Cheese
• Granola or trail mix
• Instant breakfast drinks or chocolate milk
• Milkshakes, smoothies or malts. Try to include fruits in the ingredients.
• Butter melted on bread, vegetables, potatoes and main dishes. If you use margarine, look for margarine that does not contain trans fat. If the words "partially hydrogenated fat" are in the list of ingredients, the margarine contains trans fats and should be avoided.
• Cream cheese on bagels or other breads.

The cells lining the walls of the intestines can be affected by chemotherapy, causing diarrhea. Diarrhea is classified as bowel movements that are frequent, unformed, loose or watery.

Adjust your diet based on your needs.

Possible treatments: 

• Take two loperamide tablets (for example, Imodium AD) with the first loose, watery stool. You can take up to eight tablets in 24 hours.
• Your doctor or nurse may recommend a clear liquid diet to allow the bowel to rest.

Skin care:

• Be gentle when you wipe yourself after a bowel movement. Consider using hypoallergenic personal wipes.
• Use a spray bottle of warm water to cleanse the area.
• Use a barrier cream (Desitin) after each stool.

Let your doctor know if the rectal area is sore, bleeding or if you have hemorrhoids.

Call your doctor or nurse if:

• You have five or more loose or watery stools in 24 hours.
• You are unable to drink eight to twelve glasses of clear fluid per day while having diarrhea.
• You have pain and cramping along with diarrhea.
• You feel lightheaded or dizzy.
• You have dark yellow or orange urine, or no urine in 12 hours with diarrhea. 

Constipation is when bowel movements become less frequent and stool becomes hard, dry, and difficult to pass. Constipation may be associated with nausea, bloating, and cramping. Difficulty moving your bowels may cause pain in your abdomen and pressure in your rectum. Constipation may lead to rectal bleeding. Certain chemotherapy drugs and pain medications can cause constipation.

What to do:

• Adjust your diet based on your needs.
• Be active.
• Remember that increased fiber in your diet means you need more fluids.
• Drink 8 to 12 glasses of fluids per day.
• Notify your doctor or nurse if you have constipation lasting more than two days.
• Enemas should be avoided. Check with your doctor or nurse before using.
• Take stool softeners or laxatives if recommended by your doctor or nurse.