Managing side effects of chemotherapy

Fatigue +

Tiredness and fatigue are the most common side effects of chemotherapy. You may feel very tired and weak; and daily activities might be more difficult than usual. Asking for and accepting support from people around you can really help with managing fatigue. For example, getting help with daily activities like meal preparation or shopping can help conserve your energy for other important things.
Read these tips on how to recognise and manage fatigue for people affected by cancer.

Exercise plays an important role in cancer care and can help to counteract many adverse effects before, during and after cancer treatment, including fatigue and sleep disturbance. Speak to your doctor about a referral to an accredited exercise physiologist with experience in cancer care who can recommend an exercise program tailored to you.
Read more about the benefits of exercise in cancer care and treatment.

Sleep disturbance +

Unfortunately, sleep is often affected during and after cancer treatment. This can have a significant impact on quality of life. However, there are things you can try if you are having difficulty with sleep, which you can read more about here.

Infection +

Chemotherapy treatment can result in a suppressed immune system, often due to low levels of neutrophils (a type of white blood cell which helps the body fight infection). Infections during chemotherapy treatment can be very serious. You may be prescribed a medication called pegfilgrastim (Ristempa) to stimulate your bone marrow to produce more white cells after chemotherapy. This is given as an injection under the skin, usually the day after your chemotherapy is administered.

It is extremely important to contact your treating doctor immediately if you have a temperature of 38oC or higher, or if you have chills, shivers, or shakes, as these symptoms may represent the first signs of an infection. If you cannot contact your doctor or treatment centre, you should go to the nearest hospital emergency department for assessment without delay.

Measures which may help reduce the risk of infection include: • Attention to hand hygiene • Trying to avoid germs • Keeping away from people who you know are sick with colds or flu • Staying away from crowds • Washing or peeling fruit and vegetables before eating them • Avoid eating raw fish, raw seafood, raw meat or raw eggs • Avoid swimming public pools or spas

Hair loss (Alopecia) +

Hair loss very commonly occurs as a side effect of chemotherapy treatment for breast cancer. The amount of hair loss depends on the specific chemotherapy drugs used. Hair usually starts to fall out 2 to 3 weeks after starting treatment. The hair starts to grow back from about 3 months after treatment is finished, or sometimes much sooner than this.

Some chemotherapy can also make your eyebrows and eyelashes fall out. Often these start to fall out later than scalp hair and may start growing back later also.

Many people who lose their hair with chemotherapy choose to wear a wig, or alternatively a headscarf, hat or beanie. If you purchase a wig, your health fund may subsidise the cost of this - ask your doctor for a letter to assist with this claim.

Scalp-cooling is a technique used at the Mater Hospital to prevent hair loss associated with chemotherapy. More information on scalp cooling can be found here.

Nausea and vomiting +

Chemotherapy-induced nausea and vomiting are less common nowadays because the drugs used to prevent it have improved. Anti-nausea medications are given before each chemotherapy treatment and may be continued for several days afterwards depending on your chemotherapy regimen.

The following drugs may be prescribed to prevent nausea:

• Akynzeo (netupitant/palonosetron) - a capsule taken at least one hour prior to chemotherapy.
• Aloxi (palonosetron) - an injection given just prior to your chemotherapy
• Dexamethasone injection or tablets given just prior to your chemotherapy (may also be given for a few days after treatment).

You will also be prescribed tablets such as metoclopramide (Maxolon) to take home, for use ‘as required’ in the days after chemotherapy. Maxolon (metoclopramide) (one 10mg tablet) can be taken up to three times daily as required, usually prior to meals. If metoclopramide (Maxolon) is not effective, then there are alternatives available over the counter at your local pharmacy which may be helpful, such as:

• Cyclizine (Nausicalm) - take 1/2 to 1 tablet three times daily as required; or
• Prochlorperazine (Nausetil) - take 1-2 tablets three times daily as required.

If these are not effective, there are further options available. Please contact the Patricia Ritchie Centre for further advice.

Skin care +

Dry skin may occur secondary to chemotherapy or targeted therapy. The following may assist in preventing or relieving dry skin:

• Avoid long showers
• Use soap-free wash such as Aveeno or Cetaphil body wash
• Moisturise regularly with an emollient such as sorbolone, or oatmeal-based products such as Aveeno daily moisturising lotion

A rash is a relatively common side effect to taxanes (paclitaxel and docetaxel) and Perjeta (pertuzumab). To relieve itch associated with a rash, try:

• Hydrocortisone 1% cream (available over the counter)
• If this is not sufficient, then try clobetasone (Eumovate or Kloxema) cream (available over the counter)

Plantar-palmar erythema (also called ‘hand-foot syndrome’) is a skin reaction affected the palms and soles of the feet in response to chemotherapy including capecitabine, fluorouracil, docetaxel and liposomal doxorubicin (Caelyx). It may result in redness, pain, abnormal sensation and, if severe, peeling and/or blistering of the skin.

Measures for prevention and treatment include:

• Avoiding hot water
• Regular moisturisers
• Urea creams 2-3 x daily (eg Urederm)

Further management of plantar-palmar erythema may include treatment dose reduction or temporary delays.

Constipation +

Constipation is relatively common with cancer treatment. Medications used to prevent nausea can cause constipation particularly in the days immediately after chemotherapy treatment. If you are prone to constipation, you could try the following:

• Take Coloxyl with Senna (2 tablets daily) or Movicol (1 sachet daily) the day your chemotherapy starts and continue this for 3-4 days.
• Drink plenty of fluids and include high fibre foods in your diet to keep regular.
• Try prunes and pear juice to help prevention of constipation.
• Avoiding lactulose as it tends to increase abdominal bloating and cause flatulence.

You should aim to have a bowel motion at least every two days. If needed, you can increase the dose of medications until your bowel habit returns to normal. If your bowels have not opened after three days:

• Try using one glycerine and one Dulcolax suppository inserted in the rectum.

Contact the Patricia Ritchie Centre for further advice.

Diarrhoea +

Diarrhoea can occur with chemotherapy and some targeted therapies, particularly with drugs such as fluorouracil, docetaxel, paclitaxel, capecitabine and Perjeta (pertuzumab). If you experience diarrhoea:

• Keep your fluids up and drink plenty of water.
• Take loperamide (Gastrostop or Imodium) after each loose motion as required.
• If you have tried these medications and your diarrhoea is still not controlled, speak to your doctor.
• Seek medical attention if you are having difficulty maintaining adequate fluid intake, are feeling dizzy or light-headed, or have abdominal pain or cramping.

Mouth care +

Many types of cancer treatments cause side effects in the mouth. These changes in the mouth can be very painful and uncomfortable. Some recommendations for how to manage pain and side effects in the mouth are detailed below:

Mouth ulcers or sore mouth (oral mucositis)

• Use a soft toothbrush
• Use sodium bicarbonate mouthwash four times daily (to make your own, dissolve 1 teaspoon of bicarbonate soda in a glass of water)
• Avoid alcohol containing mouthwashes
• Suck on ice blocks
• Avoid hot, spicy or rough food
• Soluble paracetamol and/or aspirin - gargle in mouth
• Difflam anti-inflammatory throat spray
• Bonjela or SM33 - apply small amount directly to ulcer prior to eating
• • Kenalog in Orabase - apply small amount directly to ulcer after eating and rinsing mouth

Dry mouth

• Sip water or sugarless drinks often
• Use sodium bicarbonate mouthwash at least 4 times a day
• Chew sugarless gum or suck on sugarless lollies to stimulate saliva flow
• Avoid caffeine, alcohol and tobacco, as these can dry out the mouth
• Apply lip balm regularly
• Biotene Oral Balance Moisturising Gel and/or Aquae mouth spray may be helpful as required

Oral thrush (candidiasis)

• May need an anti-fungal if you have oral thrush (often with white coating on tongue)
• Nilstat antifungal drops. Swish 1mL around your mouth for one minute, then swallow (no script required)
• Fungilin lozenges or Fluconazole tablets (150mg single dose tablet) can also be used as an alternative

Read more about mouth health and cancer treatment.

Eye symptoms +

Chemotherapy may cause dry eyes due to meibomian gland dysfunction, resulting in a gritty sensation, sensitivity to light and blurred vision. A result of this dryness may be excessive tearing, also called 'epiphoria’. Occasionally, narrowing of the nasolacrimal duct in the corner of the eye (which usually drains away tears) can make the excessive tearing symptoms worse.

Inflammation of the eyelids (called ‘blepharitis’) may also occur as a side effect of treatments.

The following may assist with dry eye symptoms:

• Massage lids with a warm compress (eg whilst taking a warm shower) to help the meibomian glands release lubricating oils into the tear film.
• Lubricating eye drops (eg Systane)
• If there is inflammation around the eyelids, it is recommended to avoid eye make-up in the area.

Nose symptoms +

Chemotherapy (especially docetaxel, paclitaxel) and some targeted therapies including Herceptin can cause a runny nose, and sometimes nose bleeds.

• For a runny nose, try Atrovent Forte nasal spray 3-4 times daily
• To help prevent nose bleeds, try a sesame oil nose spray (FESS or Flo brand)