How to Cope with Chemo Side Effects

Often used in conjunction with radiation or surgery, chemotherapy is drug therapy tailored to each individual cancer patient with the aim of preventing cancer spread, slowing cancer growth and killing cancer cells. Unfortunately, it can bring a host of debilitating side effects. While you probably can’t avoid all of the chemo side effects, you can take steps to alleviate them. 

‘Chemo Brain’

Chemo for any type of cancer can cause problems thinking, concentrating or remembering things. A study on breast cancer patients found that about 50% complained of cognitive impairment after chemotherapy, but the good news was only 15-20% had objective, measurable cognitive decline. 

Some patients, like Idelle Davidson of Los Angeles who underwent chemotherapy for breast cancer in 2006, experienced chemotherapy-related cognitive impact (CRCI). “After six rounds of carboplatin and docetaxel and then one year of trastuzumab infusions every three weeks, it was like a blanket of fog had descended over my brain. I couldn’t think straight. I couldn’t remember phone numbers, people’s names or calculate the tip on a restaurant tab. I got disoriented at shopping malls and directions made no sense to me,” said Davidson, who went on to co-author the book, Your Brain After Chemo, with Dan Silverman, MD, PhD.

Chemo is often part of a chain of medical interventions — surgery, anesthesia and radiation — all of which can have an impact on brain function, though most of them are temporary. So if you feel some “chemo brain,” try to give your brain some time to recover, as you do your body. 

Who: According to Cedars-Sinai Healthcare System, up to 75% of cancer patients have experienced “chemo brain” during treatment, and around a third continue to deal with it after treatment has ended. It impacts both genders equally but women may report it more often because of the hormonal treatments given with breast cancer therapy.

When: Onset, duration and intensity vary with the individual.

What to do: Davidson, who also writes the blog YourBrainAfterChemo.blogspot.com, recommends:

During chemotherapy:

• A 2018 study published in Oncotarget shows that the co-administration of the antioxidant drug, 2-mercaptoethane sulfonate sodium (MESNA) with the chemotherapy drug doxorubicin protects the brain from drug-induced cognitive decline.
• Resveratrol, a polyphenol non flavonoid compound present in pigmented vegetables and fruits, shows strong promise in preventing chemotherapy-induced cognitive decline, according to a 2018 study published in Neurobiology of Disease.

During or after chemotherapy:

• Seek out emotional support. Depression and stress also can cloud memory. Join a support group. Talk with your doctor about the pros and cons of antidepressants (which can bring their own set of side effects. See our article: Coping with the Side Effects of Antidepressants.
• Practice mindful stress reduction. A 2016 study published  in the Journal of Cancer Survivorship  reports that patients who practiced meditation or yoga had significant improvement on cognitive tests. A 2011 study published in Explore found that yoga (including stretching, breathing and relaxation) may improve “chemo brain” and quality of life for chemotherapy patients.
• Physical exercise increases cerebral blood flow, promotes the growth of brain cells, and prevents cognitive impairment. It’s a natural stress reducer as well.
• Exercise your mind. Even if it is a struggle, challenge yourself: read, do a puzzle, learn a new dance step. Cognitive training has been shown to significantly improve brain function. In a 2013 study published in Clinical Breast Cancer, researchers found that cognitive training significantly improved patients’ brain flexibility, verbal fluency and processing speed, and to a lesser extent, verbal fluency, planning, organizing, and staying on task. Another 2017 study in Supportive Care in Cancer confirmed these findings.
• If you are experiencing any memory issues, ask for a referral to a neuropsychologist for an evaluation.

It’s not always the chemo

Cognitive problems aren’t always chemo side effects. They can also be caused by age or other cancer treatments like radiation or other medications. The National Cancer Institute suggests treating common related conditions like poor nutrition, anxiety, depression, fatigue and insomnia might help. Other possible causes: pain, emotional distress, using alcohol or other substances that change your mental state. 

Diarrhea

Chemotherapy is known to alter the lining of the gastrointestinal (GI) tract, specifically the mucosal lining. “This alteration decreases the capacity to absorb nutrients and liquids resulting in shortened transit times through the GI tract. The result is increased bowel output,” explained Monica Key, NP-C, APRN, CCRN, AOCNP, oncology nurse practitioner affiliated with Norton Cancer Institute, Louisville, KY.

Who: According to Key, diarrhea often happens with certain types of cytotoxic chemotherapy. Chemotherapy drugs such as 5-fluorouracil, irinotecan, topotecan, methotrexate, cisplatin, docetaxel oxaliplatin and cytarabine often have diarrhea as a common side effect. Oral chemotherapy tends to have a higher chance of diarrhea since it is ingested directly into the GI tract and is not bypassed as it is with intravenous chemotherapy. Capecitabine is the oral (pill) form of 5-fluorouracil that often causes diarrhea as a side effect.

When:  Can occur anytime during therapy, and can be acute or chronic.

What to do:  Key recommends:

• Make sure you understand the medications you are given to use at home to combat/control the diarrhea. There are different kinds and each come with specific instructions.
• Reduce fiber intake.
• Drink a lot of fluids such as water or sugar-free, caffeine-free drinks with electrolytes.
• Know the signs of dehydration. If you are experiencing it, call your oncologist immediately. You will most likely be given intravenous fluids.
• A 2017 analysis of many studies has found that activated charcoal tablets can be helpful in diarrhea caused by medication or bacteria. Activated charcoal is known to attract and expel toxins from the Gl tract. Check with your doctor before starting. 

Patients with chronic or severe diarrhea may want to ask their doctor if they need to supplement their diet with vitamins or fortified drinks to maintain good nutrition.

Fatigue

Colleen Westerman of Lansing, MI, who underwent chemo in 2010 and 2012 for ovarian cancer, felt “completely drugged” a day after each treatment, and the exhaustion would last for four to six days. “It was sometimes so bad that I just could not keep my eyes open and would often fall asleep while talking to others,” she said.

“Most chemotherapy patients experience some form of myelosuppression, a decrease in the bone marrow’s ability to produce blood,” said Dishon Kamwesa, RN, BSN, Mercy Medical Center, Canton, OH. The most common reason for exhaustion among patients is due to anemia (lowered red blood cell count) or thrombocytopenia (lowered platelet count). It means your blood isn’t carrying enough oxygen around the body.

Who: Anyone, but more often patients in treatment for leukemias with medications such as Cytarabine.

When:  You will probably feel most exhausted for a few days after treatment, and then gradually feel better. Fatigue increases with each treatment.

What to do:  Kamwesa advises:

• See your physician if you experience overwhelming fatigue, muscle weakness, rapid heartbeat, difficulty breathing or dizziness.
• Have your blood levels monitored often to determine treatment dosage. Your physician will advise you if you need to take therapeutic doses of iron or get a blood transfusion.
• Eat foods high in iron: dark green, leafy vegetables; sweet potatoes; prunes and raisins; dried apricots and peaches; beans; meat and fish; enriched bread, cereal, and pasta; and seeds.
• Make sure you get enough sleep, nap when you can, and don’t push yourself too hard. “Basically just going to sleep was the only way I could deal with it,” said Westerman.
• A 2012 study by Osher Center for Integrative Medicine, University of California, San Francisco discovered that yogic breathing (pranayama) helps chemotherapy patients with sleep disturbances.
• Plan your exercise around your chemotherapy cycles. A 2020 study published in Medicine & Science in Sports and Exercise reports that instead of following a steady, linear plan of exercise, patients adhere to exercise regimens better when the schedule takes “bad days” into consideration: Reduce intensity the week after an infusion; ramp it up during weeks leading to treatment. 

Infections

Myelosuppression can also lead to lowered white blood cells (neutropenia), which can cause opportunistic bacterial, viral or fungal infections because of a compromised immune system, said Key. This can be one of the most dangerous chemo side effects.

Who: Patients receiving cytotoxic chemotherapy

When: The lowest point of cell circulation in the body after receiving cytotoxic chemotherapy is called a “nadir.” This low point generally happens 10 days after receiving treatment but your response might vary widely. You should feel better within the next two weeks.

What to do: Key suggests:

• Go to the emergency room immediately for assessment if you have a fever of 100.4 taken orally that lasts 30 minutes or longer.
• Stay away from anyone who is sick or who has received a live-type immunization within the past two weeks.
• If you are told you are neutropenic (lacking a sufficient number of infection-fighting white blood cells), stay away from large crowds of people. If you must be in a place with a large number of people, wearing a mask and washing your hands are imperative.
• Make sure food is thoroughly washed and cooked.
• If you are running a fever, tell your oncologist who will most likely prescribe an antibiotic. Your provider may put you on a course of antibiotics prophylactically, according to E.J. Bow, in Principles of Critical Care (2015).

Nausea/Vomiting

For Ann Pietrangelo of Williamsburg, VA, nausea began within days of the first treatment and was a constant throughout her chemotherapy in 2011 for triple-negative breast cancer. “It interfered with appetite in a big way, and I had to push myself to eat,” she recalled. Key explained that chemotherapy can alter the pathways of neurotransmitters and their receptors in the brain, stomach and inner ear, resulting in nausea and vomiting.

Who: Varies from person to person. Nausea and vomiting are two of the most common chemo side effects and can be brought on by the treatments, certain smells, or even by anxiety.

When: “There are certain chemo treatments that have more of this effect than others. Depending on the treatment, the onset can be within minutes and can last for several days,” said Kamwesa. For example, Cisplatin is one of the drugs that is used to treat breast, bladder and cervical cancer, to name a few. This specific drug has a very high incidence of nausea and is often given with antiemetics such as Zofran, Reglan, and Compazine.

What to do: Kamwesa recommends:

• Your oncologist can prescribe antiemetics. Make sure you understand completely how to take them. Call him or her if at any time you feel that your nausea or vomiting is not being properly controlled.
• Eat bland foods.
• Avoiding heavy cooking odors and other strong smells.
• Stay hydrated.

Columbia University’s Department of Surgery adds these recommendations: 

• Avoid eating your favorite foods when nauseated. You might start associating them with nausea.
• Eat small amounts every two to three hours. An empty stomach can make you queasy.
• Eat cold or cool foods.
• Ginger and peppermint are well-known tummy tamers. Drink them as tea or smell them as an essential oil.  

Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is caused by damaged nerves, resulting in tingling sensations, numbness, shooting or stabbing pain, or extreme sensitivity to temperature.

Who: Around 30 to 40% of chemotherapy patients experience this chemo side effect, according to a 2017 study published in Annals of Neurology.

When: “It can begin with the first treatment or can be due to dose accumulation,” said Kamwesa. During her treatments, Westerman experienced tingling in her fingers and numbness in her feet. When her treatment finished, she was happy to discover that most of the tingling in her fingers went away. “I was left with some numbness in my toes and parts of the balls of my feet. I was told after two years what was left would be permanent,” she said.

What to do:

• Magnesium (more than317 mg/day) from whole foods  has been shown to lower the prevalence of neuropathy and lessen its severity, says a 2018 study published in Nutrients. The most important food sources of magnesium in our population were whole grain bread and nuts. Also, coffee, dairy products, dark chocolate, banana and legumes were common sources of magnesium. Calcium was studied in the same research and found to have no effect on neuropathy.
• Avoid alcohol, which can make neuropathy worse.
• If you have diabetes, be vigilant about controlling your blood sugar. High amounts can damage your nerves.
• Be diligent about staying well-hydrated to help avoid toxicity.
• Protect yourself from extreme cold and hot temperatures to avoid burns or ischemia (restriction of blood supply).
• If you haven’t had shingles vaccine, talk to your doctor about getting it. Shingles can cause further nerve damage.
• Quit smoking. It narrows your arteries and increases neuropathy risk in people with diabetes.
• If symptoms are extreme, talk with your oncologist about lowering your chemotherapy dose or stopping treatment for a while.
• If symptoms are permanent, ask your oncologist about occupational therapy.

Hair Loss

Who: Most patients who undergo chemotherapy experience some degree of hair loss. It is one of the most common and well-known chemo side effects. The extent of the loss depends on several factors from the dose of treatment received to a person’s genetics.

When: Hair loss usually starts 2-4 weeks after treatment begins and continues until a few weeks after treatment ends. It can take months to a year to begin growing back normally. The effects of hair loss can be more than cosmetic. “Every time you look in the mirror, you know that something is wrong,” says Jo-Ann Messing, who has been treated for cancer twice. In one instance, she lost her hair, but in another, she was able to save most of it using a cold cap. “It really is a horrendous experience to wake up in the middle of the night and look at yourself in the mirror and see no hair, no eyebrows.”

What to do: 

• Consider cold-capping. Cold capping is a technique for preserving hair in which a technician places a tight, cold cap over your hair while you receive treatment. Messing emphasizes that the treatment is unpleasant, but that for her, it was worth it. “I had just been offered a brand new job, and I don’t know if I would have accepted it if I knew I was going to be losing my hair in the process. It enabled me to really go about my life and a perfectly normal way and to be very selective about the people I shared by the fact that I was having treatment with it.”
  Things to know about cold capping:
  • “It’s a much longer day” says Claudia Falzarano, Founder of Right Arm Inc, a company that provides cold caps and technicians. Cold capping, which, she says, restricts the amount of chemotherapy that flows through the hair follicles, needs to be started before the chemotherapy, and continued for 3.5 to 5 hours after your infusion.
  • Bring warm blankets and socks. “You are cold for probably about eight hours a day,” says Messing.
  • Renting the equipment and technician can be expensive and isn’t always covered by insurance. Some companies offer discounts for patients in need.
  • Cold capping can be used with most, but not all, chemotherapy regimens. 
• Be gentle. Pulling and styling can exacerbate hair loss, whether or not you use cold caps.
• Minoxidil (Rogaine), a topical treatment to put on your scalp probably won’t prevent hair loss, but may speed up its regrowth. 
• Shave your head or use hair caps so you don’t find chunks of hair in your bed or home regularly.
• Silk pillow cases may reduce pulling and tangling.