Chemotherapy

Chemotherapy is the use of medications or chemicals with cancer-fighting abilities. This is why chemotherapy is often called an anti-cancer agent. It all begins with normal cells versus cancer cells. Normal, healthy cells divide and grow in a patterned, controlled behavior. As they divide, replicas are produced. Cancer cells, on the other hand, grow out of control.

There is no apparent pattern at all. When in contact with a normal cell, the cancer cell takes over and copies itself many times over. In this way, the body becomes overburdened with cancer cells. Chemotherapy destroys cancer cells with drugs.

How does Chemotherapy Work?

Chemotherapy drugs interfere with the cancer cells' ability to grow or multiply. Different groups of drugs act on cells in different ways. Identification of the type of disease is important because certain chemotherapies work best for certain diseases. For example, a patient treated for acute myelogenous leukemia is treated with different agents than one treated with Hodgkin's disease. Even patients diagnosed with the same disease may be treated with different agents, depending on what is known to be most effective for the particular circumstances.

Chemotherapy can damage normal cells as well as cancer cells. Those normal cells most affected are ones which divide rapidly. These include the hair follicles, cells in the gastrointestinal (GI) tract, and bone marrow. Consequently, side effects can occur including: hair loss, mouth sores, and difficulty in swallowing, nausea, vomiting, constipation, diarrhea, infection, anemia, and increase risk of bleeding. These side effects will be discussed in greater detail later.

How is Chemotherapy Given?

Chemotherapy can be given in different ways. The five most common methods are:

• intravenous (IV)
• oral (PO)
• intramuscular (IM)
• intrathecal (IT)
• intraperitoneal (IP)

The intravenous route or IV is a very common way of giving medicine directly into a vein. A small plastic needle is inserted into one of the veins in the lower arm. There is some discomfort during insertion because a needle stick is required to get into the vein. After that, the administration of the medication is usually painless.

Chemotherapy flows from the IV bag/bottle, through the needle and catheter into the bloodstream. Sometimes a syringe is used to "push" the chemotherapy through the tubing.

The oral method takes the form of a pill, capsule or liquid taken by mouth. This is the easiest and most convenient method and can usually be done at home. Under certain special circumstances, chemotherapy given by other routes may also be administered at home.

Intramuscular means that the chemotherapy is given by way of an injection into the muscle. There is a slight sting as the needle is placed into the muscle of the arm, thigh or buttocks. Although, this procedure only lasts a few seconds, the effect of the intramuscular chemotherapy may last much longer. This is because the chemotherapy may be absorbed slowly through the muscular tissues and into the bloodstream.

Certain forms of cancer have a tendency to spread to the nervous system. To treat cancer that spreads to the spinal cord or brain, doctors may perform a spinal tap and inject chemotherapy into the spinal fluid. This is known as the intrathecal method of administration.

Permanent and Temporary Catheters

For some patients, IV insertions can eventually damage the veins in the arm. Some patients have small veins and some have very few accessible veins. Frequent IV insertions and too small or too few veins may prompt the doctor to recommend a permanent type of IV catheter. Permanent catheters allow patients to go home and receive chemotherapy without needing other IV's placed. Along with receiving chemotherapy and IV fluids through this catheter, patients can receive blood products and even have their blood drawn without painful needle sticks.

A common type of permanent catheter is the "Hickman" catheter. The terms "Broviac" or "Groshong" refer to a similar type of catheter made by different manufacturers. All work in similar ways.

Care of these catheters may be a little different, but the principle of insertion is similar. A thin, flexible tube is inserted into one of the central veins, commonly the external jugular vein. While under general or local anesthesia, the tube is tunneled through surface skin tissue between the neck and shoulder to another separate incision, usually on the chest or stomach wall. The entrance site will have stitches and a small bandage to facilitate healing. The exit site for the catheter is easy to see and care for, and patients must change their dressings regularly to prevent infection.

Frequent heparin flushes -- washing out the device with an anti-clotting drug -- are required to prevent blockage. Many patients learn to care for their catheter while in the hospital. Thorough teaching to patients and their families is done before discharge.

Another type of permanent catheter to a central vein is known as the implanted intravenous port. It is round in shape and is surgically inserted under the skin surface of the chest wall, between the neck and shoulder area. A nurse will insert a needle through the top skin surface to access the vein. The chemotherapy can then be given through the catheter as if it were an IV in the arm. As with the Hickman catheter, blood can be removed and received through this device. Although, there is no home care required, periodic heparin flushes are necessary.

There is also a temporary access device for administering chemotherapy that works in the same way as the Hickman catheter, but is removed before the patient is discharged. This is called the multi-lumen catheter because there are three IV lines in one plastic catheter line. Insertion is performed in the patient's room, with local numbing medication injected around the insertion site. Located near the neck, the site is kept covered with a dressing.

Intrathecal chemotherapy can be given into the spinal canal or through an Omaya reservoir. This device is surgically inserted under the scalp for direct injection of chemotherapy throughout the spinal fluid. The drugs are then given through the reservoir, rather than through the back during a spinal tap.

Lastly, chemotherapy may be given via an intraperitoneal (IP) port. This device is similar to the previously mentioned implanted intravenous port. The IP port sits under the skin and requires no specific home care. The port allows for placing chemotherapy directly into the peritoneal (i.e. abdominal) cavity. This technique is used to increase the concentration of the chemotherapy that contacts tumors in the abdomen.

Many cancer patients will receive chemotherapy sometime during the course of their disease. The goal of chemotherapy is to destroy cancer cells. The decision to administer chemotherapy is made based on its potential for destroying these cells, which is weighed against the risk of side effects from treatment as well as the risk of not receiving treatment at all. The side effects of treatment can sometimes be unpleasant, but most are temporary and subside once treatment is completed. Your physician will discuss these issues with you and involve you in the decision process.

General Issues

Chemotherapy, in general, works by interrupting cell growth and division. Different agents interact with the cell and it's DNA in different ways. While the particular form of chemotherapy that is administered is selected for its activity against a specific cancer, most chemotherapy also interrupts normal cell growth and division. In a patient, these injuries show up as "side effects." Most are temporary, or are relieved by medications that can be administered along with the chemotherapy. Some side effects may be permanent, but these are generally less common.

Side Effects

The discussion of side effects that follows is arranged from "head to toe" according to the body system affected. Each category includes helpful hints to assist in managing that particular side effect. Remember, not all patients experience every side effect, and side effects depend on the type and dose of chemotherapy along with other patient and disease factors.

Hair Loss

Hair loss (alopecia) can be a devastating side effect of chemotherapy treatment. This side effect raises many anxieties for both men and women. Frequent questions regarding hair loss include: "Will it happen?", "When will it happen?", and "How long will it last?" The answers are not always straightforward. Not all chemotherapeutic agents cause hair loss. Certain chemotherapies have a greater tendency to destroy hair follicle cells, causing loss of hair. The loss may involve areas of the head, chest, arms, legs and pubic region.

The duration of hair loss may vary from a few days to a few weeks. Often, it begins suddenly and some claim it happens overnight. For others, there is a gradual loss of hair as noticed in the bathtub or on a pillowcase. Then, the loss may increase in amount.

Hair loss is usually temporary. When healthy follicle cells have re-grown, the hair also re-grows. Do not be alarmed if there are some changes in the new hair. The texture, color, and style may be different. This is a common occurrence to which most people adjust without difficulty.

While hair loss cannot yet be prevented (clinical trials investigating ways to prevent hair loss are ongoing), there are ways to cope with this situation:

• During the loss, many find comfort in wearing a cloth cap, bandana, wig or hairpiece. Some patients purchase their wig or hairpiece before hair loss begins. In that way, the color and texture can be more closely matched to the original hair.
• Use a mild shampoo and conditioner to maintain skin and hair moisture. Try to avoid excessive shampooing since over drying can occur. You may want to limit washings to two or three times a week.
• Limit the use of hairdryers, curling irons, and chemicals such as dyes, perms and highlights to help decrease damage to existing hair follicles. During sleeping hours, a silk pillowcase will help eliminate tangling.

Mouth and Throat

The gastrointestinal system begins with the mouth. Because this is an area of rapidly dividing cells, when these cells are injured by chemotherapy, side effects may develop. Chemotherapy can cause irritation which can eventually lead to inflammation of the mouth, a condition known as stomatitis. A stinging sensation in the throat may develop and lead to dysphagia (difficulty in swallowing).

With oral hygiene and early identification of the following signs and symptoms, these conditions can be made much more comfortable. Prevention begins with good oral hygiene. Daily inspection of the mouth is the first step. Begin each day by carefully inspecting the mouth for any changes. Be sure to remove dentures, since hidden mouth sores can fester in this area.

Brush your teeth with a soft bristle toothbrush and use a non-alcoholic mouthwash after meals and at bedtime. Be sure your dentures are properly fitted, since a too tight or too loose fit can increase the risk of problems. Remove dentures when cleaning the mouth and do not wear them if irritation is present.

There are many common-sense interventions for uncomfortable mouth sores, ranging from good oral hygiene to proper diet. Following are some suggestions to assist in managing uncomfortable side effects:

• To lessen the discomfort and irritation of a dry mouth, keep the mucous membranes of the mouth moist. Many patients suck hard candies or ice chips to obtain relief.
• Avoid high-acid foods and drinks, such as orange and grapefruit juices. Instead, try apple juice and nectars. Carbonated beverages may irritate the gums and should also be avoided.
• Avoid spicy foods: some pasta sauces, tacos, and chili. Soft, bland dishes may be more tolerable.
• Keep food at room temperature or slightly cool. Very hot or cold foods can increase discomfort. Soups, mashed potatoes, noodles and jello, served at room temperature, are just a few good examples of food to try.
• If the mouth and throat appear red, be sure to alert your doctor or nurse. If white patches are noticed, notify your physician so the appropriate medication can be ordered. If there is pain, your doctor also can provide medication to ease the pain while the lining of the mouth and throat heal. Maintaining good nutrition is important to the healing process. Try to keep proteins and calories at an optimal level in your daily diet.
• The best treatment plan begins with daily inspection of the mouth and early detection of problems by you, the patient.

Nausea and Vomiting

Many people connect nausea and vomiting with chemotherapy treatment. Most people are not aware that there are many chemotherapy drugs which do not always cause these disturbing side effects. If nausea and vomiting do occur, doctors and nurses are prepared to handle such discomforts through the use of medications. Whether you have nausea and vomiting will depend on the chemotherapy you are receiving, and vary from patient to patient. If you know someone who has received chemotherapy and had much discomfort, do not automatically think this will happen to you. Some people feel nauseated more readily than others. It also takes time for some people to get used to their medication.

A change in appetite may occur during and after chemotherapy treatment. What was once a favorite food may suddenly seem distasteful. Such changes are known as "food aversions" and are very common to chemotherapy patients. If you find that a certain meal is more appealing, make it the main meal of the day. Smaller portions of food can be eaten more often or at different intervals to maintain calorie intake.

To combat nausea and vomiting, many chemotherapy patients benefit from maintaining a clear liquid diet one to twelve hours before a scheduled treatment. These liquids can include apple juice, tea, jello and chicken broth. Some other helpful hints during and after treatment include:

• Eat bland food, such as crackers or dry toast.
• Avoid overfilling your stomach by eating smaller, more frequent meals.
• Take foods which are at room temperature or slightly cooler.
• Keep the room or house full of fresh air and free of offensive odors. (Cooking odors are a problem for many patients.) Try to get fresh air until an offensive odor subsides.
• Practice relaxation and distraction techniques. Read a book or watch a favorite program on television. Pursue activities which provide a relaxing atmosphere. Listen to a favorite album or CD.

Constipation

Constipation can be another side effect from chemotherapy. If constipation is a problem to begin with, some chemotherapy drugs may intensify it. Older persons and those on low-fiber diets are also at greater risk.

Like other side effects, some patients experience constipation with chemotherapy while others do not. The following hints may help to reduce the risk of constipation.

• Drink more fluids. Water intake should be at least eight glasses a day (discuss this with your physician). This helps your body maintain soft stools.
• Eat a low-fat, high-fiber diet. Eat less fatty cuts of beef, cookies, sweets, and cottage cheese, and more lean beef products, poultry, fish, whole grain cereals, wheat breads, and vegetables.
• Daily exercise such as walking can help ease the risk of constipation. If medication seems necessary, ask the doctor to recommend a daily stool softener or laxative.
• Try to avoid straining so hemorrhoids will not develop.

Diarrhea

Diarrhea can also be a side effect of chemotherapy. Caused by the destruction of normal, dividing cells of the gastrointestinal (GI) tract, diarrhea varies from patient to patient. It is better managed if treated early. Notify your doctor or nurse if cramping, gas, or loose stools begin.

• Try to drink 8-12 glasses of water a day to make up for the loss of water in the stool. Rapid and excessive fluid loss or dehydration can be a serious condition resulting from diarrhea, so drink plenty of fluids and monitor habits daily.
• The best liquids to drink are those which are clear in color. They eliminate overwork by the bowels and guard against its irritation. Apple juice, ginger ale, tea, broth, and jello are examples.
• You may want to eliminate milk products and foods which are difficult to digest, such as cabbage, broccoli, cauliflower, corn, and spicy foods, in order to give the bowels a rest.
• Eat bananas, potatoes, and meats to maintain a normal potassium level. Potassium is needed for muscles to function properly. If you do experience symptoms of low potassium intake such as irregular heart beats and leg cramps, be sure to call your doctor.
• Keep the area around the rectum clean and moist to prevent skin irritation. Ask your physician about the use of a "suds bath" after bowel movements. Your doctor can prescribe a medicated cream, if necessary.
• Keep track of the number of stools per day. If any are bloody, or there are more than three bowel movements a day, inform your doctor.

Skin Reactions

Skin reactions can range from dry skin and skin redness to acne. Some reactions can occur during and after treatment. Not all chemotherapy agents cause skin reactions, but if you should notice any changes, alert your doctor. Most people notice a greater risk of sunburn -- even in cloudy weather. It is important to wear sunscreen on exposed areas when outdoors. Avoid use of a tanning bed. Keeping skin moist through the use of moisturizing creams can be helpful. If you are also receiving radiation treatments, this should be discussed with your radiation oncologist.

Effects of Chemotherapy on Bone Marrow

Bone marrow is found at the center of bones, especially the skull, sternum, ribs, backbone and pelvis. This is one of the sites in the body with rapidly growing cells. Red and white blood cells and platelets are produced here. They are held there until they mature and are ready to perform their vital functions in the blood stream.

Chemotherapy acts on the rapidly dividing cells in the bone marrow. Red cell, white cell, and platelet production may be interrupted when chemotherapy is given. As a consequence, the number of circulating cells in the bloodstream can become reduced over time, resulting in anemia (decreased red blood cell count), neutropenia (decreased white blood cell count), and thrombocytopenia (low platelet count).

During the course of treatment, the term nadir may be used. This refers to the point when the cells in the body are at their lowest number. This is a predictable time, depending on the chemotherapy agent used. One drug may have a nadir of 7-14 days. This means that 7-14 days after beginning chemotherapy, the red cells, white cells, and platelets will be at their lowest number in the bloodstream. After a period of time, the blood counts will begin to rise back to normal.

Infection

The white blood cells (WBC's) help the body to fight infections. When chemotherapy is introduced into the body, it destroys both the cancer-producing cells and the healthy, infection-fighting cells, decreasing the body's ability to fight off infection.

Your physician may have frequent complete blood counts (CBC's) done to closely monitor your white blood cells. When the white blood cell count begins to drop below normal, this is called neutropenia. This is the time when chances for infection are the highest. The following hints will help prevent and detect an infection:

• Good hand washing is one of the first steps for prevention of infection. This begins with soap and warm water. Be sure to lather well and use friction to clean the surfaces. This is best achieved by rubbing the hands together with a a back-and-forth motion. Include the nail beds and the webbed portions between the fingers.
• Try to keep the skin intact, since small cuts and bruises during the period of low white blood cells can harbor germs and be a good place for infection to start. If cuts and abrasions occur, clean the area well with soap and water. If the cuts are not very deep, clean them with hydrogen peroxide and cover with a sterile bandage. Call your doctor's office for further directions.
• Early signs of infection include:
  • Fever above 100.4F (37.8C)
  • Chills
  • New cough or production of sputum
  • Sore throat
  • More than three loose stools in a day
  • Pain or burning upon urination.
• Be alert to these signs and notify your doctor if they occur. If a patient with a low white cell count does develop an infection, it is usually treated in the hospital with antibiotics and possibly with medication to stimulate white cell production.

Other Blood Cells Affected by Chemotherapy

Red blood cells serve a vital function in the body by carrying oxygen. Chemotherapy destroys red blood cells, causing anemia (low red blood cell count). Symptoms of anemia include:

• Fatigue, dizziness, lightheadedness
• Shortness of breath
• Difficulty staying warm
• Chest pains

Your complete blood count (CBC) will show a drop in the hemoglobin and hematocrit. The anemia usually resolves after blood transfusions are given or when the blood count begins to rise again on its own.

If any of the symptoms occur, call your doctor or visit the emergency room. You may require a blood transfusion. This can sometimes be done on an outpatient basis. Today, many patients are asking about the direct donation of blood products from family members. If you are interested in this, speak with your doctor well ahead of time of a possible transfusion.

When your red blood counts are low, pace your activities, limiting the amount of work done in a day.

Red blood cell stimulating factors are also available which may help to prevent anemia. These are medications given to enhance red cell production in the bone marrow. Your physician may recommend these to reduce the risk of anemia.

Platelets are the blood cells which facilitate the clotting of blood to stop bleeding from an injury. These clotting cells are also destroyed by chemotherapy.

Some of the first signs of a low platelet count (thrombocytopenia) are constant bleeding from a cut and easy bruisability. Some people notice bleeding from the gums after eating a meal or brushing their teeth. A very common sign is the observance of small, pinpoint hemorrhages, known as petechiae, inside the mouth or elsewhere on the body, such as the arms and legs.

If nose bleeds occur, apply pressure to the nostrils while remaining in an upright position. Apply ice to the nose, if necessary. If bleeding continues, contact your physician immediately. Bleeding can also occur from the bladder or rectum and show up as blood in the urine or stool. If this happens, contact your physician at once. In addition:

• Avoid injury to the skin during a period when platelets are low. This means avoiding use of a razor or nail clippers. If injury does occur, apply pressure to any spots which are bleeding for at least 10 minutes. Call your physician immediately if the bleeding does not stop.
• To prevent bleeding from the mouth, use a soft bristle toothbrush. Avoid the use of dental floss until blood counts are within the normal range.
• Be sure dentures fit properly to cut down on irritation to the gums. When dentures are removed, rinse with a mouthwash low in alcohol to prevent drying out the insides of the mouth and increasing the risk of bleeding.

Bleeding can also be found in the stool when platelets are low. It is important to keep the stool soft and to refrain from straining. Straining can rupture tiny blood vessels in the rectal area and cause hemorrhoids. Straining also increases the pressure around the brain, increasing the risk of another hemorrhage. You may take a laxative to keep your bowels soft and regular.

Sexuality

Physical changes affecting sexuality, sexual relations and reproduction may occur as a result of chemotherapy. Women may notice a change in their menstrual cycle, including the absence of menstrual periods. Decreased vaginal lubrication may cause discomfort during intercourse, but may be prevented by using a water soluble lubricant (K-Y Jelly). Sperm counts in men may be decreased due to treatment. These and other side effects vary with different chemotherapy drugs. Therefore, it is important to discuss this with your doctor or nurse. A few questions to ask may be:

• What physical changes will I experience from the chemotherapy that may affect my sexuality?
• Are there any restrictions on sexual activity during or after treatment?
• Can this treatment cause infertility?
• Do you have any suggestions that enhance comfort during intercourse?

It may be difficult at first to discuss this intimate topic with strangers, but sharing your questions and feelings with a health care professional may be beneficial in maintaining a positive attitude toward sexuality and sexual relations during and after cancer treatment.

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