Understanding the Chemotherapy Process
THE MODERN ERA OF CHEMOTHERAPY
Talking about chemotherapy is like talking about the weather: on any given day, in any part of the world, there can be perfect calm or there may be a blizzard. When discussing the side effects of chemotherapy, just as when discussing the weather, it is important to avoid generalizations and not lump all chemotherapy together. The specific drugs, doses, and schedules in which chemotherapy is given as well as the patient’s constitution determine how well it is tolerated. Whereas some chemotherapy regimens are very hard on the body, others are compatible with normal routines. Before receiving chemotherapy, patients are usually given fact sheets describing the possible (likely and less likely) side effects of each medicine as well as the opportunity to meet with an oncology nurse to talk about what to expect.
Fears about chemotherapy drugs can cause great anxiety among those about to undergo treatment. A great deal of misinformation exists about their side effects. Some of this is a holdover from days long gone when cancer patients receiving chemotherapy frequently experienced nausea and vomiting as well as a greatly diminished ability to prevent certain infections. We are now in the modern era of chemotherapy, in which many of the most severe side effects have been greatly improved by a host of medications.
My intent is not to minimize the serious side effects that chemotherapy can sometimes cause and about which there is ample information. My goal is to clarify the misconceptions about chemotherapy that I frequently hear from new patients in my oncology practice.
MYTHS AND FACTS ABOUT CHEMOTHERAPY
Myth: Chemotherapy always causes nausea and vomiting.
Fact: If you are about to receive chemotherapy, visit the infusion suite where your treatment will be administered. Look around. You will see other patients receiving intravenous medications. Some will be reading, others listening to music or having a conversation. You will even see many of them eating. But you will probably not see anyone vomiting. When a cancer patient sits down to receive chemotherapy, the first medications the oncology nurse will hang on the IV pole are not the cancer-fighting drugs but rather premedication’s or “premeds.” Premeds include antinausea and other medications that reduce the risk of side effects. Advances in new medicines that prevent nausea and vomiting have dramatically improved the tolerability of chemotherapy. As a result, the chemotherapy session is often anticlimactic, even uneventful. Once at home, nausea may or may not occur. It might begin the night of treatment or the next day. If nausea does occur, then antinausea medications should be taken as directed by your oncology doctor or nurse.
Before you begin chemotherapy, make sure your doctor gives you a prescription for one (or more) of these medicines in case you need them; better to have them on hand and unused than having to call for them at 3:00 am. If they are not sufficient, call your doctor’s office at any time of the day or night and speak to the oncologist on call for help.
The chances that nausea and vomiting will occur depend on the type of chemotherapy drugs administered and on the individual; every person will react differently. Your oncology team will tell you whether the drugs you will receive are associated with a low, intermediate, or high risk of nausea. Medications and other techniques to prevent the symptoms (such as sea bands, eating ginger, and smelling lemons) will be recommended accordingly. If after the first chemotherapy session you experience excessive nausea and/or vomiting, a change in antinausea medication will be prescribed to improve the situation for the next treatment.
Overall, most patients experience only mild nausea after chemotherapy. For some, nausea may last for one or a few days and then disappear. Others find that they always have a low level of nausea while undergoing therapy that does not prevent them from eating; still others come to expect “one good puke” the morning after that rights their systems. Whichever pattern you may experience, the management of this miserable side effect is infinitely better than it was a decade ago.
Myth: Chemotherapy wreaks havoc on the immune system.
Fact: This fear relates to the fact that some (but not all) chemotherapy drugs can lower the white blood cell (WBC) count and, consequently, the body’s ability to fight certain infections. The specific kind of WBC that protects against bacterial infections is called a neutrophil; a low neutrophil count is called neutropenia. A normal neutrophil count is above 1,800 in Caucasians and 1,400 in African Americans. The risk of infection rises substantially when the neutrophil count is less than 1,000 and especially under 500. Infection is often heralded by a fever called neutropenic fever. This can be life threatening when not addressed in a timely manner.
If you are receiving chemotherapy and you experience a fever (100.4 degrees or above), contact your oncologist right away, even if it is the middle of the night. Do not take fever-reducing medicines on your own and try to sleep it off. Owing to major advancements in science, medications now exist to bolster a person’s WBC and neutrophils; they have dramatically reduced the risk of severe infections experienced by cancer patients. They include: filgrastim (Neupogen), sargramostatin (Leukine), and pegfilgrastim (Neulasta, a longer-acting Neupogen), which are administered as subcutaneous injections. These “drugs” are actually natural chemicals made by our bodies to stimulate bone marrow function.
Surprisingly, most of the infections that affect the neutropenic cancer patient come from the body; the E. coli and other bacteria that normally reside in the intestinal tract are a major source. Other sources of infection may be rotten teeth, breaks in the skin, or catheters placed for the purpose of receiving chemotherapy.
Oncologists may prescribe a WBC growth factor in two ways:
(1) To treat neutropenia (and especially neutropenic fever) when it occurs after cancer treatments; or
(2) To prevent neutropenia through administration of the medication on the day or days following chemotherapy.
Only some patients undergoing chemotherapy will require the use ofa WBC growth factor. Their need depends on the intensity of the cancer treatment as well as on aspects of their condition and history. Patients who have had chemotherapy or radiation therapy in the past, those with low blood counts before starting chemotherapy (for reasons their doctor should investigate), and the elderly are more prone to develop neutropenia from chemotherapy.
It is important to realize that WBC growth factors do not eliminate neutropenia and the risk of infection; despite their use, strong chemotherapy will still cause neutropenia. Rather, by minimizing the duration or number of days of neutropenia, WBC growth factors limit the time during which a patient is most susceptible to infection.
Although there will always be a risk of infection with chemotherapy, the proper use of WBC growth factors and antibiotics, along with the oncology team’s close attention to the patient’s condition, has made “a wreck of the immune system” a thing of the past.
Myth: Chemotherapy always causes baldness.
Fact: Some but not all chemotherapy drugs cause significant hair loss. Science has not found a way to prevent this side effect. The hair will grow back, usually beginning about four to six weeks after the completion of therapy. In some cases, hair may regrow while a patient is receiving the chemotherapy that made it fall out in the first place (this does not mean that the chemotherapy is no longer working). The first growth is like peach fuzz; eventually resulting in a wavy, soft new head of hair (sorry, but gray hair will not come back as dark hair). In contrast, some chemotherapy drugs may only cause hair thinning, and others will have little effect on hair growth. Many patients find it best to prepare for possible or expected hair loss by visiting a wigmaker before their hair falls out and by cutting their hair short once chemotherapy has started; they should carry a prescription for a “cranial prosthesis” so that the cost is covered by insurance. Any cancer center is clearly full of individuals (patients and staff) who are familiar with this process and able to provide excellent advice.
Myth: Chemotherapy causes weakness and an inability to carry out normal activities.
Fact: If you are experiencing symptoms from cancer, then effective chemotherapy will make you feel better, not worse. Only when the cancer is treated can the body heal.
For any cancer patient, however, chemotherapy may certainly contribute to weakness. The longer treatments go on, the more likely it is that fatigue will be a part of a patient’s life. But this fatigue is usually not debilitating. Most patients undergoing chemotherapy will be able to function in their lives with some modifications. Parents may need help at home; workers may need to cut back their hours or take time off to complete treatment; travel is often minimized. The types of treatments and the patient’s physical condition and age are again critical determinants of the severity of fatigue.
Anemia, or a low red blood count, is one reason for weakness. Some cancers suppress bone marrow activity, which can lead to anemia before chemotherapy starts. Blood levels of folic acid, vitamin B12, and iron should also be checked; the oncologist may need to consider unrelated bone marrow disorders if severe anemia is present and unexplained.
When chemotherapy causes anemia, it is not immediate but rather emerges after two or three cycles of treatment. Chemotherapy may lower red blood production just as it does white blood cell production. In such cases, injections of red blood cell (RBC) growth factors, called erythropoietin (Procrit) or darbopoietin (Aranesp), are administered. Erythropoietin is the hormone that our kidneys normally make to stimulate the bone marrow to generate red blood; all patients receiving dialysis for kidney failure receive these medications.
Other factors that may contribute to weakness include insufficient rest, inadequate nutrition, depression, anxiety, stress, and psychological distress caused by what cancer is doing to the patient’s life. I encourage every cancer patient to discuss these issues with his or her oncologist and to seek help in addressing them with professionals such as clinical social workers and psychiatrists. There is no value in suffering through cancer and its treatments; the short-term use of medications or psychological counseling can do a world of good.
Myth: Chemotherapy destroys good cells along with the bad.
Fact: Each chemotherapy drug has a number of well-established side effects that oncologists discuss with their patients before treatment.
Most centers provide patients with chemotherapy fact cards or sheets that describe common and less common side effects caused by the drugs to be used. Similar to common medications filled by prescription, the lists of possible side effects from a chemotherapy drug are long (and often frightening). And like any other medication, only a fraction of the listed side effects will occur; the intensity of each side effect will also vary from person to person.
Just as only certain chemotherapy drugs cause significant nausea, hair loss, or fatigue, some drugs are associated with the potential to cause damage to the heart, lungs, kidneys, reproductive organs, or other organs. This damage, or decline in function, may be temporary or long lasting. It may be mild (not noticed by the patient) or “clinically significant,” which means that the problem is affecting the patient’s ability to function normally. In order to monitor “the rest of the body” and not just the cancer, vital organ function is tested at regular intervals during cancer treatment and for many years after treatment has finished.
It should be noted that if a patient has some impairment of vital organ function before beginning treatment (such as kidney insufficiency or congestive heart failure), then some chemotherapy drugs will be administered in reduced doses and others will be avoided.
Even for those chemotherapy drugs associated with damage to a particular organ, the damage is usually avoided if precautions are taken. For example, when the drug cisplatin (Platinol) was introduced in the 1960s, its anticancer activity was remarkable, but it also caused kidney failure in the first studies and was nearly abandoned. Fortunately, it was shown that if extra fluids were given intravenously along with the drug, kidney failure could be averted. Cisplatin went on to cure testicular cancer and is used safely today in a variety of cancers. Patients receiving cisplatin today are told to drink fluids liberally before and for twenty-four hours after administration.
As part of the education process before chemotherapy, cancer patients will be informed of any possible organ damage from the drugs they will receive and any precautions that may be taken to minimize these risks. Some side effects are hard to prevent, such as the sensation of tingling and/or numbness in the tips of the fingers and toes, called peripheral neuropathy. Culprit drugs include bortezomib (Velcade), cisplatin (Platinol), docetaxel (Taxotere), oxaliplatin (Eloxatin), paclitaxel (Taxol), vinblastine (Velban), and vincristine (Oncovin). Although the symptoms of peripheral neuropathy diminish over time, they may persist, even faintly, for months or years after treatment. Because of this, patients are monitored closely for early symptoms so that the treatment regimen can be altered (if possible) to prevent severe neuropathy. Oncologists may also prescribe medications to alleviate the symptoms, such as amitriptyline (Elavil), nortriptyline (Pamelor), gabapentin (Neurontin), pregabalin (Lyrica), and duloxitene (Cymbalta). The usefulness of supplemental vitamins E, B6, and B12 is under study. Caution: alcoholic drinks may worsen peripheral neuropathy.
Some chemotherapy drugs as well as radiation therapy may contribute to (or directly cause) the development of new cancers many years after treatment. Treatment-related cancers are called secondary cancers. This is not a common occurrence, although its frequency is not known with certainty because of the difficulty in distinguishing secondary cancers from new cancers that were destined to arise anyway. As more people are cured of cancer, the true incidence of treatment-related cancers will become clearer. Cancer survivors are routinely monitored for secondary cancers by their health care team.
If a particular treatment is linked to subsequent cancers, then researchers have tried to find equally effective alternatives. An example would be the change from a chemotherapy regimen called MOPP to another one named ABVD for the treatment of Hodgkin lymphoma; ABVD offers a lower risk of leukemia and even better outcomes. Also, lower doses of radiation are now being used to treat Hodgkin lymphoma in order to minimize the risks of future breast and lung cancers. Visit www.cancer.net to learn more about the short-term and possible long-term effects of chemotherapy.
Myth: Once chemotherapy is started, it cannot be stopped until the recommended treatment course has been completed
Fact: As a patient, the decisions to initiate and terminate medical treatments are your own. Chemotherapy may be stopped after the first cycle, the first injection, the first pill. If you are a patient and you feel strongly about terminating treatments prematurely, then it is extremely important that you discuss your reasons for doing so with your oncologist.
It may be possible to rectify unpleasant reactions to treatment or change the therapy to a more acceptable alternative. If in the end, you wish no further treatment, the oncologist should honor and respect your wishes. Yet the end of cancer treatment does not mean the end of patient care; ongoing physical symptoms and emotional distress caused by cancer will still need to be addressed. Good communication is the key to a rewarding and strong patient-physician relationship.
In conclusion, chemotherapy saves lives. It can cure some cancers and extend survival in many others. But the drugs can be unpleasant and cause unwanted side effects, even though the “chemotherapy experience” has dramatically improved in recent years. And it has been known for decades that chemotherapy alone cannot eradicate the advanced stages of the most common cancers. For this reason, researchers have been dissecting the molecular details of cancer cells in the hopes of uncovering targets for more selective and, it is hoped, more effective drugs. The targeted therapies that have resulted have already begun to revolutionize the management of cancer.
