Chemotherapy is any treatment involving the use of drugs to kill cancer cells. Cancer chemotherapy may consist of single drugs or combinations of drugs, and can be administered through a vein, injected into a body cavity, or delivered orally in the form of a pill. Chemotherapy is different from surgery or radiation therapy in that the cancer-fighting drugs circulate in the blood to parts of the body where the cancer may have spread and can kill or eliminate cancers cells at sites great distances from the original cancer. As a result, chemotherapy is considered a systemic treatment.
More than half of all people diagnosed with cancer receive chemotherapy. For millions of people who have cancers that respond well to chemotherapy, this approach helps treat their cancer effectively, enabling them to enjoy full, productive lives. Furthermore, many side effects once associated with chemotherapy are now easily prevented or controlled, allowing many people to work, travel, and participate in many of their other normal activities while receiving chemotherapy.
Being informed about chemotherapy and its potential side effects can help you to proactively manage your own care and optimize your treatment and outcome. Things you may need to know include the following topics:
- Chemo Brain
- How is chemotherapy delivered?
- Understanding and Monitoring Your Blood Count
- When to Call Your Doctor
- Frequently Asked Questions
This often-unexpected side effect of cancer treatment leaves many patients experiencing debilitating cognitive effects after chemotherapy. Luckily, research and awareness are catching up.
By Beverly Burmeier
Ten years ago Sharon Palmatory’s trouble remembering names and numbers after chemotherapy treatment for breast cancer might have been brushed aside as an insignificant occurrence, considering survival was the primary concern. But today, thanks to early diagnosis and effective treatment, more women survive breast cancer than ever before, and quality-of-life issues like this are increasingly important.
“It’s a definite medical condition,” says Dr. Christina Meyers, PhD, ABPP, professor of neuropsychology in the Department of Neuro-Oncology at M. D. Anderson Cancer Center in Houston, describing what has come to be known as “chemo brain,” a lesser-known side effect of chemotherapy, which can be just as serious as nausea, fatigue, and hair loss. Thankfully, the condition—marked by a reduction in verbal or visual memory, problems with attention and concentration, a reduction in the speed of processing information, and visual or spatial abnormalities—is the subject of several recent studies, as researchers seek clues to the cause and the cure of this foggy mental condition.1
“Those involved in long-term follow-up care for survivors are well aware of their patients’ complaints that they cannot mentally function as well after treatment as before,” says Dr. Mark Noble, professor of genetics at the University of Rochester School of Medicine and Dentistry in Rochester, New York. Too many people are affected to ignore the syndrome—and not just breast cancer patients or women. Men experience the foggy mental state associated with chemotherapy, too. As a result, oncologists and nurses now make a better effort to provide patients with information about the possibility of cognitive impairment occurring either during or after active treatment.
Still, many patients are surprised by the debilitating impact of the condition. “I honestly didn’t know this would happen,” says Sharon, 39, of Morgantown, West Virginia. “I was more concerned with fatigue and taking care of my family.” But after her second chemotherapy treatment, she went into a general fog for a week. “I couldn’t multitask,” she says of the way the devastating side effect affected her demanding career as a multimedia designer for government projects. “Losing my train of thought was scary. And I couldn’t manage the household, remember names and numbers, or balance my checkbook.”
Following her fourth treatment, Sharon hit her lowest point, after which improvement started slowly. “I still have a one-track mind, although treatment ended several months ago,” she says. “I always have a pad of paper to write things down.” She laughs that at her age she can’t attribute these lapses to senior moments. “I rely on my husband to remind me of appointments. The exit door to my garage is plastered with notes.”
Recognizing the Condition
Doctors used to think that impaired cognitive ability was related to other side effects of chemotherapy. Anemia, fatigue, depression, and hormonal shifts can all cause memory lapses and concentration difficulties. But treating these conditions didn’t solve the problem for many patients. And assessing the severity was difficult because there was no baseline data of mental function before chemotherapy.2
“We now know that chemo brain is a manifestation of central nervous system toxicity that occurs in many cancer patients on active therapy and may persist for 45 percent of patients after treatment is discontinued,” says Dr. Meyers. Researchers also believe that some people have genes that make cancer more responsive to treatment. This puts normal tissue at risk for changes and makes them more susceptible to mental effects from chemotherapy.
“We know a fair deal about the damage done to the brain by radiation but virtually nothing about the effects of chemotherapy,” says Dr. Noble. “Imaging studies have shown clearly that high doses of chemotherapy result in changes.” What isn’t known yet is which chemotherapy drugs cause problems and how.
What Are the Newest Findings?
Fortunately for breast cancer patients (the type of cancer most frequently studied for cognitive impairment), chemo brain is currently a hot topic in the lab. Researchers are discovering more about how the brain and the nervous system are affected by toxic drugs used in chemotherapy. Still, not everyone is affected, and scientists haven’t ferreted out enough clues to determine who is at risk.
With aggressive treatment the cure rate for Stage I cancers has grown as high as 90 percent, yet not every woman with breast cancer needs chemotherapy, although most get it, says S. David Nathanson, MD, surgical oncologist at Henry Ford Health System in Detroit. That’s significant because up to 25 percent of women who do receive it will be affected by chemo brain—a statistic that complicates the decision about who should get chemo.
Despite advances in brain research during the past decade, the exact mechanisms for cognitive impairment aren’t clearly understood, although it’s recognized that standard chemotherapeutic agents can kill normal brain cells. Dr. Noble’s research is attempting to understand how stem cells function, with the hope of using them to prevent abnormal reactions or to successfully repair damaged tissue.
“If we can’t prevent the damage, can we repair it by stem cell or precursor cell transplantation?” he asks. “It may be possible to use brain cell transplantation to restore normal function, much as bone marrow transplantation is used to restore normal function of the hematopoietic system (organs and tissues involved in the production of blood) following cancer treatment,” he says.
Dr. Noble explains further: “In many ways, a cancer cell can be thought of as the evil sibling of a stem cell. Understanding the features that distinguish cancer cells from normal cells may enable cancer-specific treatments to be developed without negatively affecting quality of life for long-term survivors.” It may also help researchers develop a means of selectively protecting normal cells from damage caused by radiation and chemotherapy.
“The only way to prevent or treat cognitive impairment associated with cancer therapy is to understand why it occurs,” Dr. Noble adds. “One of our concerns is to be able to better understand the reason for different outcomes. Understanding why some people are resistant to these effects will enable us to protect those who are more vulnerable, perhaps by modifying treatment accordingly.”
Two major studies are being conducted at the University of Sydney Cancer Centre in Australia by oncologist Janette Vardy, MD. By studying brain scans and blood tests from breast cancer patients (other research is with colorectal cancer), her team has found that those who never received chemotherapy, although they had breast cancer, had functional MRI scans more like those of healthy control persons—and different from those of patients who had received chemotherapy. “What we don’t know is how those scanned differences will relate to how a person copes in normal life,” Dr. Vardy says.
In tests on the central nervous systems of experimental animals, Dr. Noble’s team has found that during chemotherapy there is a long-lasting reduction in cell division in the hippocampus of the brain, an action believed necessary for normal memory function. “Our work shows that there is damage to the insulation (myelin) that surrounds axons, with eventual loss of the cells that produce the myelin. A lack of myelin could also cause cognitive problems.”
Breakthroughs may also result from research by Jame Abraham, MD, director of the Comprehensive Breast Cancer Program at West Virginia University’s Mary Babb Randolph Cancer Center. His team is one of the first to investigate which specific changes in the brain lead to memory loss. Early research shows differences in the white matter in the front part of the brain in women who had received chemotherapy—differences that correlate with their slower speed in processing information. “Our preliminary findings suggest that chemotherapy may change the brain, and those changes affect the patient’s cognitive skill,” Dr. Abraham says. West Virginia University researchers also concluded that these changes do not appear to be caused by depression or anxiety.3 For those affected, Dr. Abraham’s research regarding direct damage to the brain from chemotherapy brings validation to their claims.
What’s a Patient to Do?
Sharon Palmatory, a patient of Dr. Abraham’s, has suffered typical side effects from her treatment. She explains: “I feel like I’m always two paces behind—always struggling to keep up. When I lose my train of thought, it’s hard to get it back.” The problem was severe enough for her to request a transfer to slower-paced work with less aggressive deadlines. (Dr. Meyers says 14 percent of affected people have to discontinue work altogether.) “I couldn’t predict my reaction to treatment on any given day,” says Sharon. Disorganization and distractibility, when it occurred, affected her ability to perform at her previous level.
Although ongoing research is bringing physicians closer to developing targeted treatments for preventing or treating chemo brain, patients like Sharon are left to cope with various levels of cognitive impairment. Many will recover normal or near-normal levels a year or two after chemotherapy, but quality of life in the interim requires implementing strategies for dealing with the mental haze. “Maintaining function is important,” says Dr. Meyers. Sharon agrees, saying brain function is a “use it or lose it” issue.
In an instructional video provided to patients, Dr. Meyers outlines several types of cognitive impairment that fall under the “chemo brain” label:
- Reduced memory capability, both verbal and visual (“What’s your name again?”)
- Lack of focused attention or ability to process information (must read a paragraph several times to get the meaning)
- Learning new things takes longer (even though you’re still as smart as before)
- Multitasking is overwhelming (can’t talk on the phone and cook dinner at the same time)
- Easily distracted (“Why did I come in this room?”)
- Missing key points in discussion (“Please repeat what you just said”)
- Inability to find right word in conversations (You can’t just say “duh”)
- More effort required for usual tasks (daily activities leave you very fatigued)
Learning Adaptive Behaviors
“Although it can be aggravating, having chemo brain is better than the alternative,” reminds Dr. Meyers. After ruling out other possible causes of memory problems, such as stress, depression, or medications, you can help yourself cope by incorporating these suggestions into your daily routine 4:
- Try relaxation training to help focus your attention.
- Write in a journal or diary to see what influences your memory problems.
- Set a routine or schedule that you follow consistently every day.
- Ride it out—settle in for the day and watch television or funny movies.
- Exercise; aerobic exercise helps your mood and increases alertness.
- Alter your work environment or expectations: simplify.
- Learn what your cognitive strengths are and capitalize on those. (What time of day is best for tackling tasks?)
- Compensate for weaknesses by using external memory aids (daily planner, notes, maps, and reminder phone calls).
- Discuss frustrations about slower moments with friends and family.
Regarding software products that are marketed as memory-building tools, Dr. Meyers says that repetitive mental exercises just don’t work. “You might get better at the specific game, but the skills don’t carry over to your life. For example, you might get better at Nintendo and still forget your friend’s name.”
Help from the Pharmacy
At this point no drugs have proved successful for combating the effects of brain tissue damage. A small study conducted by Sadhna Kohli, research assistant professor at University of Rochester, showed improvement in memory, concentration, and learning for people taking Provigil® (modafinil), a drug that stimulates the brain only as required and lasts about 12 hours. Unlike Ritalin® (methylphenidate), which some patients have tried, Provigil is nonaddictive.
It’s also important that doctors assess and treat possible contributing factors such as thyroid dysfunction, hormonal imbalance, or anemia. As researchers come to better understand the mechanisms of chemo brain, genetic factors may play a larger part in treatment plans.
Sharon has found help close to home. Her mother is also being treated for cancer. Staying active and having a sense of humor help, she says. “It’s really important to be around people who understand you’ve gone through treatment.”
There are a variety of schedules and techniques used to deliver chemotherapy and yours will depend on which treatment your doctor prescribes. Cancer chemotherapy may consist of a single drug or combinations of drugs that are delivered in cycles. A cycle consists of treatment with one or more drugs followed by a period of rest.
Chemotherapy can be administered orally in the form of a pill, into a vein (intravenous), injected into a body cavity (such as the bladder), into a muscle (intramuscular), or into the spinal fluid (intrathecal). Currently, most chemotherapy is administered intravenously; however, oral chemotherapy drugs are gaining wider use. In some cases, it may be beneficial to administer IV chemotherapy through a venous access device (VAD), which is inserted into a major vein in the body and can remain in place for a long period of time. Not every chemotherapy patient requires a VAD. However, for those that are undergoing frequent treatment, blood tests, and nutritional support, a VAD is beneficial by reducing the number of needle sticks and associated discomfort.
How often will I receive chemotherapy?
What are the advantages and disadvantages of oral chemotherapy drugs?
What is a venous access device (VAD) and what types are used for cancer patients?
Who needs a VAD?
What special precautions are necessary with a VAD?
Chemotherapy drugs are typically given in cycles. The cycle consists of the day(s) the drug is administered followed by a rest and recovery period. A cycle usually lasts one to four weeks and is then repeated, which means a treatment is administered every one to four weeks. Each course of chemotherapy is different, but generally consists of four to six cycles. The actual administration of some chemotherapy drugs may take only seconds or minutes, while others may take hours or even days.
In the past, chemotherapy drugs were mainly administered into a vein (intravenous). Recently, oral chemotherapy drugs are being developed. Oral drugs may provide greater ease of administration since patients can take them at home rather than going to a clinic or hospital for treatments. Not all chemotherapy drugs are available in oral form. Furthermore, intravenous (IV) administration is sometimes preferable because the doctor can be more certain that the patient received the appropriate dose as scheduled and they can monitor the patient during administration.
A VAD is a surgically implanted device that provides long-term access to a major vein. Although there are several different types of VADs, the two most commonly used for cancer treatment and taking blood samples are:
- Tunneled external catheters (Hickman® catheter), or
- Subcutaneous implanted ports (port-a-cath).
Both a Hickman® catheter and a port-a-cath are surgically implanted into a major vein. For the Hickman® catheter, the plastic tube or catheter is attached to a major vein and then comes out of the body for external access. A port-a-cath is implanted completely beneath the skin into a major vein under the collarbone. The port may then be accessed by a special needle through the skin to deliver chemotherapy, hydration, transfusions, and for taking blood samples.
The following are some key features that distinguish these two types of VADs:
- Easier insertion, removal, and access
- Higher flow capacity due to single, double, or triple lumen (channel)
- Fewer device-related infections
- Fewer activity restrictions
- Less day-to-day maintenance
- Lower flow capacity due to only single or double lumen (channel)
Patients undergoing very demanding therapies that require frequent treatment, blood transfusions, and nutritional support—such as a stem cell transplant—may be required a Hickman® catheter instead of a port.
Not every chemotherapy patient requires a VAD. For some chemotherapy treatment plans, the inconvenience of implanting and accessing a VAD may outweigh the benefits. You may wish to ask your doctor if a VAD is an appropriate option for you, especially if you experience any of the following:
- You are extremely anxious about having needles inserted.
- Your veins are difficult to access or become inaccessible.
- You must have alternative veins in your foot or hand accessed, which may be associated with more discomfort.
- You are undergoing continuous infusion chemotherapy (over an hour).
- You anticipate many months of chemotherapy treatments.
- You are receiving intravenous chemotherapy that requires multiple needle sticks.
- Your treatment requires frequent drawing of blood samples.
- Your treatment strategy involves chemotherapy agents that may cause “vein pain” when administered through the arm.
- You have a physician or nurse who recommend a vascular access device.
Your VAD must be flushed in order for it to work properly. Flushing your VAD requires placing a needle in your port and flushing it out with heparin. Heparin is a blood thinner prevents the catheter (plastic tube) from becoming occluded (clogged). While you are on treatment, your VAD will be flushed after each treatment. When you are no longer on treatment you must still remember to have your VAD flushed regularly. This procedure needs to be done every 4-6 weeks. It is your responsibility to make the appointment to have your VAD flushed.
A reduced number of blood cells in circulation is a common side effect of chemotherapy. Blood is composed of three basic blood cell types: red blood cells, white blood cells, and platelets. Blood cells are produced in the bone marrow and regularly released into circulation. Chemotherapy destroys rapidly dividing cells, a characteristic of cancer cells. However, bone marrow cells also divide rapidly and are frequently damaged by chemotherapy. Blood counts are monitored with a laboratory test called a Complete Blood Count (CBC). The best way to treat low blood counts is to prevent them before they occur. This can be accomplished with the administration of blood cell growth factors. In some circumstances, blood transfusions may also be necessary.
What are low blood counts?
What causes low blood counts?
What are the symptoms of low blood counts?
Why is it important to monitor low blood counts?
How are low blood counts diagnosed?
What are the treatments for low blood counts?
A blood count is a measurement of the number of blood cells an individual has in circulation based on laboratory evaluation of a blood sample. Blood is composed of three basic blood cell types: red blood cells, white blood cells, and platelets. You should have billions of these blood cells circulating throughout your body. However, certain circumstances may cause you to have fewer cells than is considered normal, a condition which is called “low blood counts”. The laboratory test that is conducted to measure the number of blood cells is called a complete blood count, or CBC.
The most common reason cancer patients experience low blood counts is as a side effect of chemotherapy. Chemotherapy involves the use of drugs to destroy cancer cells. Chemotherapy works by destroying cells that grow rapidly, a characteristic of cancer cells. Unfortunately, chemotherapy also affects normal cells that grow rapidly, such as cells in the bone marrow that produce red blood cells, white blood cells, and platelets.
Your symptoms will depend on which types of blood cells are low. Common symptoms of the different types of low blood cell counts are listed in table 1.
Table 1: Common symptoms of low blood counts
|Low red blood cells||Low white blood cells||Low platelets|
|Fatigue or tiredness||Infection||Excessive bruising|
|Trouble breathing||Fever||Excessive bleeding|
|Difficulty staying warm|
It is important to monitor for low blood cell count because this condition may:
- Increase your risk of unpleasant and sometimes life-threatening side effects, such as fatigue, infection, and/or bleeding.
- Disrupt delivery of your cancer treatment, resulting in a change to the planned dose and time.
A test called the complete blood count (CBC) is used to determine whether your blood counts are low. The CBC measures the levels of the three basic blood cells: red, white, and platelets.
In the United States, the CBC is typically reported in the format shown below. If your blood counts fall outside of the normal range, which is shown in the “Reference interval” column, their values will be reported in the “Flag” column with an ‘L’ for low and an ‘H’ for high. The example CBC below shows that white blood cells, red blood cells, and platelets are all low.
|CBC WITH DIFFERENTIAL|
|White Blood Count||1.5 L||x 10-3/mL||4.0-10.5|
|Red Blood Count||3.50 L||x 10-6/mL||4.70-6.10|
|Polys (absolute)||.34 L||x 10-3/mL||1.8-7.8|
|Lymphs (absolute)||1.0||x 10-3/mL||0.7-4.5|
|Monocytes (absolute)||0.1||x 10-3/mL||0.1-1.0|
|Eos (absolute)||0.1||x 10-3/mL||0.0-0.4|
|Basos (absolute)||0.0||x 10-3/mL||0.0-0.2|
Result column: The result column shows counts that fall within the normal range.
Flag column: The flag column shows counts that are lower (“L”) or higher (“H”) than the normal range.
Reference interval (or reference range) column: The reference interval shows the normal range for each measurement for the lab performing the test. Different labs may use different reference intervals.
White blood cells: White blood cells help protect individuals from infections. The above CBC report shows that the patient’s total white cell count is 1.5, which is lower than the normal range of 4.0-10.5. The low white cell count increases the risk of infection.
Differential: This portion of the CBC shows the counts for the 5 main kinds of white cells, either as percentages (the first 5 counts), or as the absolute number of cells (the second 5 counts).
Absolute neutrophil count: Neutrophils are the main white blood cell for fighting or preventing bacterial or fungal infections. In the CBC report, neutrophils may be referred to as polymorphonuclear cells (polys or PMNs) or neutrophils. The absolute neutrophil count (ANC) is a measure of the total number of neutrophils present in the blood. When the ANC is less than 1,000, the risk of infection increases. The ANC can be calculated by multiplying the total WBC by the percent of polymorphonuclear cells. For example, this patient’s ANC is 0.34, which equals (WBC) 1.5 x 23%.
Red blood cells: Red blood cells carry oxygen from the lungs to the rest of the body. The above CBC report indicates that the patient has a red cell count of 3.5, which is lower than the normal range of 4.70-6.10, and therefore, shown in the flag column.
Hemoglobin (Hb or Hgb): Hemoglobin is a protein in the red cell that carries oxygen. The above CBC report indicates that the patient’s Hb count is 10.8, which is below the normal range of 14.0-18.0. The hematocrit (HCT), another way of measuring the amount of Hb, is also low. This means that the patient has mild anemia and may be starting to notice symptoms.
These three ranges will vary depending on age and gender. For women, they will be lower than those shown here. For example, the Hb reference interval for a woman is 12.0-16.0.
Platelets: Platelets are the cells that form blood clots that stop bleeding. The above CBC report indicates that the platelet count for this patient is normal.
The best treatment for low blood counts is to prevent them before they occur. This can be accomplished with the administration of blood cell growth factors. Blood cell growth factors are substances produced by the body that stimulate the cells in the bone marrow to produce more red blood cells, white blood cells, or platelets. These factors have also been produced in a laboratory and are approved by the Food and Drug Administration (FDA) for the treatment of cancer patients with low blood counts.
Low red blood cell counts: Erythropoietin is a blood cell growth factor that selectively increases production of red blood cells. Clinical trials have demonstrated that erythropoietin is safe and effective in reversing anemia in cancer patients.5,6 Erythropoietin has been proven to effectively:
- Increase hematocrit
- Decrease the need for blood transfusions
- Reverse fatigue
- Improve overall sense of well-being
Erythropoietin is FDA-approved for the treatment of anemia in patients with nonmyeloid cancers (cancers that do not involve blood cells), whose anemia is a result of chemotherapy.
Treatment with erythropoietin causes a gradual increase in red blood cell production. The body uses iron in red blood cell production. Thus, supplemental iron may be required to adequately support erythropoietin-stimulated erythropoiesis. Virtually all patients receiving erythropoietin therapy will eventually require supplemental iron therapy.
Currently, there are two commercially available forms of erythropoietin for use in patients, epoetin alfa (Epogen® or Procrit®) and darbepoetin alfa (Aranesp® ). Both are manufactured in the same facility in the same manner. Epogen® and Procrit® have been in use for many years. Aranesp® is a unique, longer-acting form of erythropoietin and is more convenient because it allows patients to receive fewer injections than with Epogen® or Procrit®. The most common side effects seen in clinical trials with Aranesp® were fatigue, edema, nausea, vomiting, diarrhea, fever and shortness of breath. No important differences in side effects were seen between groups treated with Aranesp® and groups treated with the existing anemia treatment, Epogen®.
Low white blood cell count: The blood cell growth factors approved by the FDA for the prevention of chemotherapy-induced neutropenia are Neupogen® (filgrastim) and Neulasta® (pegfilgrastim).7,8 Multiple clinical trials have shown that Neulasta® and Neupogen® reduce the severity and duration of low white blood cell counts associated with many kinds of chemotherapy regimens. By increasing white blood cell counts, Neupogen® has been shown to decrease a patient’s risk of fever and admission to the hospital. The drawback of Neupogen®, however, is that it must be administered daily. In two clinical trials, a single dose of Neulasta® has been proven to be as effective as an average of 11 daily injections of Neupogen® for the management of neutropenia. The most common side effect you may experience with Neulasta® is aching in the bones. If this happens, it can usually be relieved with a non-aspirin pain reliever, such as acetaminophen. It is also possible to have an allergic reaction to Neulasta®.
Low platelet count: The blood cell growth factor approved by the FDA for the prevention of low platelet count is called Neumega®. Clinical studies have shown that Neumega® prevents thrombocytopenia and decreases the need for platelet transfusions in patients at high risk for developing a low platelet count. Neumega® has been reported to cause palpitations, fluid retention and diarrhea as well as other side effects in some patients.
Transfusions: In some cases, low blood counts may be so severe that you may need to undergo a blood transfusion. Red blood cells and platelets are often transfused. Sources for transfusional blood include blood banks or your own blood that you had stored for future use before undergoing treatment. Transfusions may be associated with complications, including allergic reactions that may range from mild to life-threatening. In general, it is better to prevent low blood counts than to treat them once they occur.
The development of any of the following symptoms during your chemotherapy treatment may indicate a serious condition. If you experience any of the following throughout your cancer treatment, please inform your doctor.
- Fever higher than 101º F
- Shaking chills
- Vomiting that continues 48 hours after treatment
- Bleeding or bruising
- Shortness of breath/chest pain
- Severe constipation or diarrhea
- Painful or frequent urination
- Blood in the urine or stool
- Soreness, redness, swelling, pus, or drainage at your VAD site
- Irregular or rapid heart beat
- Pain in a new place.
- Pain that is not relieved by your pain medication.
- Headache that is not relieved by Tylenol®
- Inability to eat and continued weight loss
- Mouth sores
- Nasal congestion, drainage, cough
- One or more of the following symptoms in conjunction with repetitive diarrhea or vomiting (signs of dehydration):
- Dry, cracked lips
- Dry, sticky tongue
- Increased thirst
- Decreased urination
- Increased weakness
- Increased pulse rate
- Dizziness/lightheadedness (especially when rising to a standing position)
How does chemotherapy work?
How is chemotherapy given?
How often will I receive chemotherapy?
What chemotherapy will I receive?
How is my chemotherapy scheduled?
What are the side effects of chemotherapy?
Why am I so tired?
Will my chemotherapy make me sick?
What tests will be performed?
Why is my complete blood count (CBC) tested after treatment?
Will I lose my hair because of my treatment?
Chemotherapy kills rapidly-dividing cells in a variety of ways, depending on the drug. Since there are many different types of cancers that all grow differently, many chemotherapy drugs have been developed to target these various growth patterns. Each drug has a different way of working and is effective at a specific time in the life cycle of the cell it targets. For example, some chemotherapy drugs work by:
- Damaging DNA,
- Preventing cells from dividing, or
- Disrupting cellular metabolism or other critical functions.
Chemotherapy can be given:
- Intravenously (IV),
- By mouth in the form of a pill,
- With a shot (injection), or
- By intrathecal and intraventricular injection (meaning into the spinal fluid surrounding the spinal cord or brain).
Many types of chemotherapy can be given at home. Through instruction, you and your family members can learn how to administer chemotherapy in pill form or by injection with small syringes and needles similar to those that people with diabetes use to administer insulin. In some cases, a nurse will administer chemotherapy in an outpatient clinic. In other cases, it may be necessary to go to the hospital to receive treatment.
Chemotherapy is typically given in cycles, which is a treatment followed by a period of rest. A cycle can last one or more days, but is usually one, two, three, or four weeks long. A course of chemotherapy is comprised of multiple cycles. Each course is different, but generally consists of four to six cycles. It may take a relatively short period of time to receive some chemotherapy drugs, while others take hours. It all depends on the treatment regimen that your doctor recommends.
If your chemotherapy is given through an IV, your doctor may suggest an implanted venous access device (VAD) such as a Hickman® catheter or Port-a-Cath. VADs are surgically placed in a large vein near the heart and can stay in place for long periods of time. By using a VAD, you will not have to have smaller catheters repeatedly placed in your arm veins.
Generally, treatments are given daily, weekly, or monthly. How often you receive chemotherapy depends on the type of cancer and which drug or combination of drugs you receive. Your doctor will help you determine the most effective treatment schedule for you. Chemotherapy is usually given in cycles with rest periods between each administration.
Chemotherapy may be used in combination with surgery. When chemotherapy is given before surgery it is referred to as neoadjuvant chemotherapy. The goal of neoadjuvant chemotherapy is to shrink the cancer before it is surgically removed. If the chemotherapy is given after surgery, it is referred to as adjuvant chemotherapy. The goal of adjuvant chemotherapy is to kill any cancer cells left in the body after surgery. Regardless of whether it is given before or after surgery, chemotherapy will still be administered in cycles that depend on the type of cancer and which drug or combination of drugs.
You will receive chemotherapy that is best suited to achieve your goals of therapy. When selecting a treatment or treatments, your doctor will consider:
- Your diagnosis
- How far along your cancer is in its development
- The expected behavior of the cancer
- Where the cancer originated
- Your age
- Other medical problems you may have
- Any potential side effects from the treatment.
Chemotherapy is typically given in cycles, which is a treatment followed by a period of rest. A cycle can last one or more days, but is usually one, two, three or four weeks long. A course of chemotherapy is comprised of multiple cycles. Each course is different, but generally consists of four to six cycles. The actual administration of the chemotherapy drugs may take minutes to several hours, depending on the drug or drugs given.
If your chemotherapy is given through an IV, your doctor may suggest an implanted venous access device (VAD) or Port-a-Cath. VADs are surgically placed in a large vein near the heart and can stay in place for long periods of time. By using a VAD you will not have to have smaller catheters repeatedly placed in arm veins.
Chemotherapy works by destroying cancer cells; unfortunately, it cannot tell the difference between a cancer cell and a healthy cell. The delivery of cancer therapy often affects the body’s normal tissues or organs that are not affected by cancer. Side effects, or complications of treatment are the undesired consequence of affecting normal cells.
Side effects of treatment may cause inconvenience, discomfort, and occasionally even fatality to patients. Additionally and perhaps more importantly, side effects may prevent delivery of the full dose of chemotherapy on schedule. This is extremely important to understand since your expected outcome from chemotherapy is based on delivering treatment at the full dose and schedule prescribed in the treatment plan Because the expected outcome from therapy is based on delivering treatment at the prescribed dose and schedule, a change from the treatment plan may reduce your chance of achieving an optimal outcome. . This is extremely important to understand. In other words, side effects not only cause discomfort and unpleasantness, but may also compromise your chance of cure by preventing the delivery of therapy at its optimal dose and time.
The most common side effects of chemotherapy are low blood counts, nausea, vomiting, hair loss, and fatigue. Some side effects may be temporary and merely annoying. Others, such as infection or a low white blood count, can be life-threatening. For example, one of the most serious potential side effects of chemotherapy is a low white blood cell count – a condition called neutropenia (new-truh-pee-nee-ah) – which can put you at risk for severe infections or treatment interruptions.
Fortunately, last 20 years has brought a great deal of progress in the development of treatments to help prevent and control the side effects of cancer therapy. These developments have
- Led to vast improvements in the management of symptoms associated with cancer treatment
- Allowed for greater accuracy and consistency concerning the administration of cancer treatment
- Made many cancer treatments more widely available to patients throughout the world.
Many people who receive chemotherapy experience fatigue. Fatigue has many causes but frequently occurs because of anemia caused by the chemotherapy. Your daily activities should be planned according to how you feel, and you should take rest periods throughout the day as often as you feel necessary. Anemia can be effectively treated. To learn more, go to fatigue.
Without receiving special anti-nausea medications, most patients will experience some nausea after treatment with chemotherapy. Nausea and vomiting may last 24-48 hours. The severity of nausea and vomiting mainly depends on which chemotherapy drugs were used. A number of very effective medications called anti-emetics or anti-nausea drugs are now available to help lessen or prevent nausea and vomiting. These medications may be given to you intravenously during your chemotherapy, or you may be given a prescription medication to take at home. To learn more, go to nausea and vomiting.
Your doctor determines what kinds of tests are needed. If you are receiving chemotherapy, you may have blood work done anywhere from the day of or up to 7 days before your scheduled treatment. This blood work will include a complete blood count (CBC), chemistry profile, and any necessary cancer markers. A blood sample for a complete blood count (CBC) will also be collected seven to fourteen days following your chemotherapy. It is important to be aware of possible symptoms of reduced red blood cell (RBC), white blood cell (WBC), or platelet (PLT) production. Be sure to report any of the following:
- Fever (over 101º F), congestion, or a cold.
- A rash, blister, easily bruised skin, signs of bleeding, an infected cut, itching or burning in the genital area.
- Weakness, fatigue, or shortness of breath.
Chemotherapy destroys rapidly dividing cells, a characteristic of cancer cells. However, red blood cells, white blood cells, and platelets also divide rapidly and are frequently damaged by chemotherapy. Your red blood cell count, white blood cell count, and platelet count may all go down. Your doctor monitors these counts to determine the toxicity of treatment and to predict your risk for complications, as well as to plan future therapy. For more information, see section on Understanding and Monitoring Your Blood Counts.
Hair loss occurs with some, but not all, chemotherapy drugs. The amount of hair loss varies from a slight thinning to complete baldness and affects the scalp, eyelashes and eyebrows, legs, armpits, and pubic area.
Hair loss will typically begin two or three weeks after your first treatment. The amount of hair that you lose will depend on the type of chemotherapy drug you are taking. Hair typically begins to grow back approximately 2-3 weeks after treatment is finished. The hair may grow back differently than it was before treatment. For example color or texture (curly or straight) may be different.
Remember that hair loss associated with chemotherapy is temporary and the hair WILL grow back. In the meantime, here are a few tips to help you cope with the loss:
- You may wish to cut your hair before it starts falling out. The experience of losing the hair is sometimes worse than dealing with it once it’s gone. If you expect to lose all or a lot of your hair, cutting it first may be easier to cope with.
- Plan ahead; shop for a wig before your hair is gone, especially if you wish to match your natural color. Or, take this opportunity to try something different.
- Try hats or head scarves; these are good alternatives or a compliment to a wig.
- Remember to cover your head or use sunscreen on your scalp. Skin that has been covered with hair may be particularly sensitive to UV rays of the sun.
- Ask your insurance company if they cover the cost of the wig.
- Treat your new hair gently once it grows back. Avoid chemicals, bleach, peroxide, or colors.
1 Tannock IF, Ahles TA, Ganz PA, Van Dam FS. Cognitive impairment associated with chemotherapy for cancer: Report of a workshop. Journal of Clinical Oncology. 2004;22(11):2233-39.
2 Chemo Brain. American Cancer Society Web site. Available at:http://www.cancer.org/docroot/MBC/content/MBC_2_3x_Chemobrain.asp. Accessed June 22, 2008.
3 Abraham J, Haut MW, Moran MT, Filburn S, Lemiuex S, Kuwabara H. Adjuvant chemotherapy for breast cancer: Effects on cerebral white matter seen in diffusion tensor imaging. Clinical Breast Cancer. 2008;8(1):88-91.
4 Chemobrain: When Cancer Treatment Disrupts Your Thinking and Memory. Mayo ClinicWeb site. Available at:http://www.mayoclinic.org/diseases-conditions/chemo-brain/manage/ptc-20170264. Accessed June 22, 2008
5 Glaspy JA, Jadeja J, Justice G. Optimizing the management of anemia in patients with cancer: a randomized, active-controlled study investigating the dosing of darbepoetin alfa [abstract]. Proceedings of the American Society of Clinical Oncology 38th annual meeting; May 18-21, 2002. Abstract 1446.
6 Kotasek D, Albertson M, Mackey J. Randomized, double-blind, placebo-controlled, dose- finding study of darbepoetin alfa administered once every 3 (Q3W) or 4 (Q4W) weeks in patients with solid tumors [abstract]. Proceedings of the American Society of Clinical Oncology 38th annual meeting; May 18-21, 2002. Abstract 1421.
7 Vose J, Crump M, Lazarus H. Randomized, multicenter, open-label study of pegfilgrastim compared with daily filgrastim after chemotherapy for lymphoma. Journal of Clinical Oncology. 2003;21: 514-519.
8 Green M, Koelbl H, Baselga J. A randomized double-blind multicenter phase III study of fixed-dose single-administration pegfilgrastim versus daily filgrastim in patients receiving myelosuppressive chemotherapy. Annals of Oncology. 2003:14:29-35.