Managing side effects of cancer treatment
• Pain is often measured by the numeric pain
intensity scale – how bad is your pain on a scale
of 1-10 with one being the least amount of pain
– Nociceptive pain – pain that is caused by an injury to
body tissues – aching, sharp, or throbbing
– Neuropathic pain – pain that results from damage to
peripheral or central nervous system – shooting
– Acetaminophen – i.e. Tylenol – good for mild pain– Nonsteroidal anti-inflammatory drugs – NSAIDS –
i.e. Motrin/Advil – effective for many types of
cancer-related pain, especially pain caused by
inflammation (post-op pain) – can be used
routinely to manage acute and persistent pain
acute and persistent pain – i.e.
Fentanyl - opioid side effect management:
constipation – initiate bowel regiment
(softener and laxative), sedation, nausea,
- local anesthetics – topical or injectable
local anesthetics are effective in reducing pain
-coanalgesics – tricyclic antidepressants – first
line treatment for neuropathic pain- opioids – tramadol
Central nervous system neuropathies caused by
oxaliplatin and 5-FU – NCI Common Toxicity
Criteria for Neurotoxicity – Grade 0-Grade 4
neuroleptics and tricyclic antidepressants or
Severe neuropathy can be treated with opioid
Things you can do to manage rashes:
When bathing use a mild soap with out perfumes.
When washing and drying the skin gently pat the area instead of rubbing with the towel or washcloth.
Use sunscreen or protective clothing when out in the sun, even on cloudy days.
Previous history of skin tanning without damaging burns or skin reactions to sunlight does not indicate that skin wil respond
the same way while on chemotherapy or radiation.
Drugs that may be prescribed by your doctor:
Antihistamines to treat an allergic response.
Analgesics (pain medications) if a painful rash is present.
When to cal your doctor or health care professional about skin reactions:
Swelling, chest pain or difficulty breathing (signs of an allergic reaction). Seek help immediately and notify your health care
Fever of 100.5º F (38º C) or higher, chills (possible signs of infection).
Itching, pain or other troubling symptoms accompanying a rash.
Rash affecting the mucous membranes in the mouth or nose.
Any blistering, peeling, open areas in the skin.
If you suspect an infection in the skin or nails.
• Treatment interventions for chemotherapy-induced
diarrhea – CID – common with irinotecan:
– Immodium – standard first line therapy– High-dose loperamide - (diarrhea associated with
- Somatostatin analog (octreotide acetate) – second-line
- Tincture of opium – antidiarrheal agent – second line
therapy for CID – two types – not to be confused
Treatment interventions for radiation-induced diarrhea:
- Oral opiates – including immodium and lomotil – standard
Evaluation of dietary intake is VERY important as
there are food and fluids that may exacerbate
diarrhea – I encourage you to adopt the following
Consume at least 8-10 servings (8 oz each) of liquid
Choose liquids such as Gatorade, diluted fruit juice
(50-50 juice and water), broth, or noncaffeinated
• Avoid substances that contain sorbitol• Avoid food that exacerbate diarrhea - raw fruits and vegetables,
whole grain bread, nuts, popcorn, skins, seeds, legumes, greasy,
fried, and high-fat foods, foods and beverages that contain lactose,
large quantities of fruit juice, sweetened fruit drinks, caffeinated
• try to choose food that bulk stools, including high soluble fiber
foods, such as applesauce, oatmeal, bananas, cooked carrots, and
rice; low insoluble fiber foods such as noodles, cream of wheat,
well-cooked eggs, white toast canned or cooked fruit w/o skin,
skinned turkey or chicken, fish, mashed potatoes
• Choose foods that replete electrolytes, including foods high in
sodium and potassium such as bananas, peach nectar, apricot
Complementary therapies – herb teas, aloe vera juice several times a day, flax or
linseed seeds crushed into food or chewed
Bulk laxatives – bran, metamucil, citrucel
Saline laxatives – milk of magnesia, magnesium citrate, sodium phosphate
Osmotic laxatives – lactulose, sorbitol
Stimulant laxatives – bisacodyl (dulcolax); castor oil
• Anticipatory nausea and vomiting – a
conditioned or learned response that occurs
chemotherapy in which nausea and vomiting
was not controlled – prevention is key:
Behavioral therapies such a relaxation, hypnosis,
Also, benzodiazepines – Xanax or Ativan
• Acute and delayed nausea and/or vomiting –
acute occurs w/in minutes to several hours
after chemotherapy administration and often
resolves w/in 24 hours; delayed occurs more
administration – peaks at 48-72 hours and can
Persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual
-develop an activity/rest plan for carrying out priority activities
-delegate more fatiguing or less-valued activities
- schedule more strenuous or high-priority activites during peak energy periods
- pace activities to prevent overexertion and loss of energy reserves
- maintain activity levels to prevent progressive loss of function
Plan and carry out energy restorative activities, such as:
- eating a wel -balanced, nutritious diet
- enhance restful sleep, maintain a regular sleep schedule, provide a quiet environment, plan a
warm bath at bedtime, administer mild sedatives as indicated
- engage in stress management/coping activities
- participate in a regular exercise program, developed in consultation with a physiatrist or physical
therapist, to maintain or improve functional capacity
Request medications or treatments to relieve discomforts (such as pain or nausea) that exacerbate
fatigue or decrease tolerance for activity
Experts have been studying memory for a long time. There are many resources that might help you sharpen your mental abilities and manage the problems that may come with chemo
Use a detailed daily planner. Keeping everything in one place makes it easier to find the reminders you may need. Serious planner users keep track of their appointments and schedules,
"to do" lists, important dates, phone numbers and addresses, meeting notes, and even movies they'd like to see or books they'd like to read.
Exercise your brain. Take a class, do word puzzles, or learn a new language.
Exercise your body. Regular physical activity is not only good for your body, but also improves your mood, makes you feel more alert, and decreases tiredness (fatigue).
Eat your veggies. Studies have shown that eating more vegetables is linked to keeping brain power as people age.
Set up and follow routines. Pick a certain place for commonly lost objects and put them there each time. Try to keep the same daily schedule.
Don't try to multi-task. Focus on one thing at a time.
Ask for help when you need it. Friends and loved ones can help with daily tasks to cut down on distractions and help you save mental energy.
Track your memory problems. Keep a diary of when you notice problems and the events that are going on at the time. (You might track this in your planner.) Medicines taken, time of
day, and the situation you are in may help you figure out what affects your memory. Keeping track of when the problems are most noticeable can also help you prepare. You'll know to
avoid planning important conversations or appointments during those times.
Write down questions to talk over with your doctor about the problems you have. Ask what may be causing them, and find out if there is anything the doctor can offer to help you.
If your memory and thinking problems keep causing trouble in your daily life, ask your doctor if you might be helped by a neuropsychologist. These professionals can test brain function
and possibly recommend ways to help you deal better with the problems. You'll want to find out what your insurance will cover before you start.
Try not to focus so much on how much these symptoms bother you. Accepting the problem will help you deal with it. As many patients have noted, being able to laugh about things you
can't control can help you cope. And remember, you probably notice your problems much more than others do. Sometimes we all have to laugh about forgetting to take the grocery list
Another thing you can do to better manage chemo brain is tell family, friends, and your healthcare team about it. Let them know what you are going through. You may feel relieved once
you tell people about the problems you sometimes have with your memory or thinking.
You are not stupid or crazy -- you just have a side effect that you have to learn to manage. Even though this is not a change that is easy to see, like hair loss or skin changes, your family
and friends may have noticed some things and may even have some helpful suggestions. For instance, your partner may notice that when you are rushed, you have more trouble finding
things. Tel your loved ones what they can do to help. Their support and understanding can help you relax and make it easier for you to focus and process information.
Many large hospitals and cancer centers have neurologists, psychoneurologists, and psychologists who are experts at testing brain function, including the symptoms of chemo brain.
Testing can help specialists find the extent of your symptoms and then suggest the best mental exercises for you. You may want to ask to be referred to one of these specialists who can
help you learn the scope of your problem and work with you on ways to manage it.
Following administration of chemotherapy, small amounts of drug leak out of very small blood vessels called capillaries in the palms of the hands and soles of the feet. Exposure of your hands and feet to heat as well as friction on your palms and soles increases the amount of drug in the capillaries and increases the amount of drug leakage. This leakage of drug results in redness, tenderness, and possibly peeling of the palms and soles. The redness, also known as palmar-plantar erythema, looks like sunburn. The areas affected can become dry and peel, with numbness or tingling developing. Hand-foot syndrome can be uncomfortable and can interfere with your ability to carry out normal activities.
Things you can do if you suspect hand-foot syndrome (Palmar-Plantar Erythrodysesthesia):
Prevention is very important in trying to reduce the development of hand-foot syndrome. Actions taken to prevent hand-foot syndrome will help reduce
the severity of symptoms should they develop.
This involves modifying some of your normal daily activities to reduce friction and heat exposure
to your hands and feet for a period of time following treatment
(approximately one week after IV medication, much as possible during the time you are taking oral (by mouth) medication such as capcitabine).
Avoid long exposure of hands and feet to hot water such as washing dishes, long showers, or tub baths.
Short showers in tepid water will reduce exposure of the soles of your feet to the drug.
Dishwashing gloves should not be worn, as the rubber will hold heat against your palms.
Avoid increased pressure on the soles of the feet or palms of hands.
No jogging, aerobics, power walking, jumping - avoid long days of walking.
You should also avoid using garden tools, household tools such as screwdrivers, and other tasks where you are squeezing your hand on a hard surface.
Using knives to chop food may also cause excessive pressure and friction on your palms.
Cold may provide temporary relief for pain and tenderness caused by hand-foot syndrome.
Placing the palms or bottoms of your feet on an ice pack or a bag of frozen peas may be very comforting. Alternate on and off for 15-20 minutes at a time.
Rubbing lotion on your palms and soles should be avoided during the same period, although keeping these areas moist is very important between treatments.
Emollients such as Aveeno®, Lubriderm®, Udder Cream®, and Bag Balm® provide excellent moisturizing to your hands and feet.
Over the counter pain relievers such as acetaminophen (Tylenol®) may be helpful to relieve discomfort associated with hand-foot syndrome. Check with your doctor.
Taking Vitamin B6 (pyridoxine) may be beneficial to preventing and treating Plantar-Palmar Erythrodysesthesia, and should be discussed with your doctor.
Drugs/treatment changes that may be prescribed by your doctor:
Chemotherapy treatments may need to be interrupted or the dose adjusted to prevent worsening of hand-foot syndrome.
• Associated with xeloda, 5-FU, irinotecan –
• Treated primarily symptomatically with oral
cleansing, rinsing, topical agents, and pain
• Therapy breaks or dose restrictions can
Prevention and treatment
There have been numerous studies trying many different medications and interventions to reduce the incidence and severity of oral mucositis.
Unfortunately, only a few of these interventions have shown much success. It is known that a good oral care regimen (see below) can help in
preventing or decreasing the severity of mucositis and can help prevent the development of infection through open mouth sores. The mainstay of an
oral care regimen is mouth rinses, and numerous studies have determined that just plain old salt water is the best and most cost effective mouth
rinse available. A mouth rinse aides in removing debris and keeping the oral tissue moist and clean. Other important components include using
mouth and lip moisturizers, using a soft-bristle toothbrush, maintaining adequate intake of fluids and protein, and avoiding irritating foods, alcohol
Rinse mouth (swish and spit) before and after meals and at bedtime with either:
Normal saline (1 tsp of table salt to 1 quart (32 oz.) of water)
Salt and soda (one-half tsp of salt and 2 tbsp of sodium bicarbonate in 1 quart of warm water)
Use a soft-bristle toothbrush after meals and at bedtime. If the brush causes pain, toothettes may be used
Use a non-abrasive toothpaste (or mix 1 tsp baking soda in 2 cups water). Avoid toothpastes with whiteners.
Keep lips moist with moisturizers. Avoid using Vaseline (the oil base can promote infection).
Avoid products that irritate the mouth and gums:
Avoid commercial mouthwashes and those with alcohol
Limit use of dental floss, DO NOT use with platelets below 40,000
Do not use lemon or glycerin swabs or toothbrushes without soft bristles
Try to include foods high in protein in your diet.
Avoid hot, spicy or acidic foods, alcohol, hard or coarse foods (crusty bread, chips, crackers).
Remove whenever possible to expose gums to air
Loose fitting dentures can irritate the mouth and gums and should not be worn
Do not wear dentures if mouth sores are severe
Do not smoke cigarettes, cigars or pipes. Do not use smokeless tobacco (chewing tobacco, snuff)
Cryotherapy, which involves sucking on ice chips during chemotherapy administration, has shown some effect in preventing mucositis caused by 5-
FU (fluorouracil). Two agents, Gelclair® and Zilactin®, are mucosal protectants that work by coating the mucosa, forming a protective barrier for
exposed nerve endings. These agents resulted in improved pain control, and ability to eat and speak in clinical trials. Other agents that have been
studied include: capsaicin (derived from chili peppers), glutamine, prostaglandin E2, Vitamin E, sucralfate, and al opurinol mouthwash.
Pain is a significant problem related to mucositis and warrants early intervention. In mild cases, ice
pops, water ice, or ice chips may help numb the area, but most cases require more intervention for
Topical pain relievers include lidocaine, benzocaine, dyclonine hydrochloride (HCl), and Ulcerease®
(0.6% Phenol). One of the issues of using topical agents is the inability to effectively coat all areas
and that the pain relief is brief. In patients with mucositis that do not achieve pain relief with
topical agents, narcotic analgesia is often necessary. This may require a hospital admission for
intravenous (IV) pain medications until the mucosa begins to heal, particularly in patients unable to
swallow. It is important to note that this side effect is temporary and the use of narcotics for the
relief of pain caused by mucositis will be temporary as well. Patients should not “suffer through it”
to avoid using narcotics, they will not become addicted to them when used for this very real pain.
One popular topical agent is “magic mouthwash” a mix of lidocaine, diphenhydramine and Maalox.
This has not been proven effective and Maalox further dries the tissue, which can add to the
complication. It is best to use lidocaine alone in a swish and spit method.
Research continues into many new agents to prevent or treat mucositis, but at this point, it remains
a challenging, costly, and distressing side effect.
• Feel free to contact me with questions –
• ALWAYS talk to your healthcare provider about
any and all side effects – even if they weren’t
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