Doctor, Doctor: Focus on Chemotherapy
Network - Summer 2010
We asked Millie Toth, senior nursing instructor in the Department of Nursing Professional Development, to give us an overview of the side effects cancer patients may face during and after chemotherapy.
What are the most common side effects of chemotherapy?
Because chemotherapy attacks fast-dividing cells, side effects are triggered in places where such cells are common, like the bone marrow, the gastrointestinal (GI) tract, the skin and hair follicles.
Low white blood cell conditions, like leucopenia and neutropenia, might put patients at increased risk for infection. Frequent hand washing is the best way to minimize this risk.
Other patients may develop anemia when their red blood cell count is reduced. Anemic patients may notice increased fatigue, a fast heartbeat and shortness of breath. When platelet levels are reduced, as in thrombocytopenia, bleeding precautions must be implemented, such as shaving with electric razors and minimizing activities that have increased potential for trauma.
GI tract symptoms may include oral mucositis (sore mouth), pharyngitis (sore throat), esophagitis (difficulty swallowing), nausea and vomiting, diarrhea and loss of appetite (anorexia). With certain chemotherapy agents, such as vinca alkaloids like vincristine and vinblastine, constipation may be a side effect as well.
Can you explain the nausea and vomiting that accompany chemotherapy?
The degree of nausea and vomiting depends on the treatment regimen. The agent(s), dose and route may all contribute to its intensity. We’ve learned a lot about the causes of vomiting over the past few years. Several agents help eliminate or minimize the vomiting reflex. Ondansetron (Zofran®) and aprepitant (Emend®) block different “vomiting” receptors to minimize nausea and vomiting.
If you’re on a highly emetogenic (vomit-inducing) regimen, it’s important to maintain a constant blood level of the antiemetic (vomit-preventing) agent until the chemotherapy has been eliminated from the body. Don’t wait until you “sense” nausea to take nausea medication; instead try taking it 30-60 minutes before a meal.
Do you alert patients to the side effects they might encounter?
Yes. Patients must be aware of the agents and treatment they’ll receive, including rationale and proactive management of potential side effects. Patients need to realize that they’re part of the treatment team.
I recommend that they and their families learn as much about their disease and treatment as possible. Patients should advocate for themselves, and monitor and have a basic understanding of important blood values, such as platelet, neutrophil, hemoglobin, renal and liver function levels.
I urge patients to maintain a “diary” binder to record side effects (from zero to 10), write questions for their doctors, take notes and file routine blood values/reports for reference. This “logging” may help patients better understand and manage this experience, and gain more control.
Can you tell us more about the types of nausea and vomiting cancer patients might experience?
Yes. Some of the common terms associated with nausea and vomiting are:
- “acute” nausea/vomiting happens within the first 24 hours of receiving chemotherapy;
- “delayed” nausea/vomiting occurs more than 24 hours after receiving chemotherapy;
- “anticipatory” nausea/vomiting is a conditioned, learned response that occurs after a negative experience with chemotherapy, when the nausea/vomiting was uncontrolled;
- “breakthrough” nausea/vomiting occurs when initial coverage for nausea/vomiting is inadequately maintained; and
- “refractory” nausea/vomiting is the inability to prevent nausea/vomiting.
Different agents are used to manage each type of nausea/vomiting. The Place ...of wellness provides additional non-pharmacologic supportive options, including acupuncture, acupressure, guided imagery, music therapy, progressive muscle relaxation and more. Dietary options such as small, frequent meals, ginger candy or drinks, soda crackers and lemon water have demonstrated decreases in nausea and vomiting as well.
What can patients do on their own to deal with these side effects?
Management of these side effects is addressed in educational material available from the Patient Education Office at MD Anderson. Find the Patient Education Office home page via the Resources tab.
If you’re able to visit MD Anderson’s main campus, pick up a spiral manual titled “Guide to Managing Your Chemotherapy Treatment” that summarizes management of each side effect noted above, and more. It is free of charge for cancer patients and their family members. The Place … of wellness is another beneficial resource for symptom management.
You have an interest in the side effect called oral mucositis, or sore mouth. What is it, and how is it treated?
When the fast-dividing cells are challenged by chemotherapy and/or radiation to the oral cavity, the normal mucosa — the moist tissue that lines the mouth — thins, and patients may note an increase in soreness/pain in the oral cavity, resulting in difficulty eating and swallowing.
The best approach to managing this condition is to be proactive with routine management. Before starting chemotherapy/radiation to the oral cavity, it’s recommended that patients visit a dentist to get an evaluation of oral status, the necessity for dental work and a good cleaning to remove calculus build-up. Routine oral care with a soft toothbrush and a basic fluoride toothpaste should be performed at least four times a day, and teeth should be flossed daily with a waxed floss.