Cancer

Types and Side Effects of Chemotherapy

Chemotherapy for Cancer

Chemotherapy is commonly used as a treatment for cancer, but the word "chemo" alone can bring a sense of dread. What exactly is chemotherapy, when and how is it used, and what are the potential side effects? What questions should you be asking your doctor? Though chemotherapy can still be challenging, management of many of the feared side effects has improved dramatically in recent years.

It's been said that knowledge is power.

We hope this discussion will leave you feeling empowered as you face this part of your cancer journey.

What Is Chemotherapy?

Chemotherapy is a type of cancer treatment that uses medications to treat cancer. It may also be referred to as cytotoxic chemotherapy, with the term 'cytotoxic' referring to the fact that these medications are toxic (cause death) to cancer cells. Not all cancer medications are referred to as chemotherapy.

For example, targeted drugs, immunotherapy, and hormonal therapy are different approaches to treatment that may be given as a drug.

A cell becomes cancerous when an accumulation of mutations (damage to DNA) cause it to reproduce and divide out of control. Chemotherapy drugs work by interfering with the normal reproduction and cell division of rapidly growing cells. For this reason, cancers that grow rapidly (aggressively) often respond well to chemotherapy. In contrast, slow-growing tumors, such as some types of lymphoma, do not respond as well, or at all, to these treatments.

Some normal cells in our bodies divide rapidly as well, such as those in the hair follicles, bone marrow, and digestive tract.

This accounts for the well-known chemo side effects of hair loss, bone marrow suppression, and nausea. 

Why Chemotherapy?

To better understand the purpose of chemotherapy and why it's used to treat cancer, it’s important to consider cancer treatments in two different ways: local treatments and systemic (total body) treatments. Local treatments, such as surgery and radiation therapy, treat cancer where it begins. Chemotherapy—along with targeted therapies and immunotherapy—are instead considered systemic treatments. These treatments address cancer cells that are present anywhere in the body, not just the original site of the cancer.

If a cancer has spread beyond its initial location (metastasized) or if there is a chance that it has spread, systemic treatments such as chemotherapy are needed. This can be better explained with an example. Surgery for breast cancer can remove a tumor in the breast. But if any cells at all have spread beyond the breast to lymph nodes or other organs—even if only a few cells have spread but cannot yet be detected with scans—surgery is unable to remove those cells and chemotherapy is often needed.

Blood-based cancers such as leukemia are present in cells that circulate throughout the body, and therefore systemic treatments alone are usually used.

When Is Chemotherapy Given?

Chemotherapy may be given for different reasons and with several different goals in mind. It's important to talk to your doctor and understand the exact purpose of chemotherapy as part of your treatment regimen. In fact, recent studies have found that patients and physicians often differ in their understanding of these goals. The purpose of chemotherapy may be:

  • Curative therapy: With blood-related cancers, such as leukemia, chemotherapy is often given with the intent of curing the cancer. With curative therapy, your treatment may be broken down into induction chemotherapy, which is the initial step in treatment, followed by consolidation chemotherapy, which follows.
     
  • Adjuvant chemotherapy: Chemotherapy may be given as an adjuvant treatment—that is, along with other treatments for cancer. A common example of this is when chemotherapy is used for people with early stage breast cancer—cancer which may or may not have spread to lymph nodes, but has not spread to other organs in the body. In this example, chemotherapy is used as a method of eradicating any tumor cells that have traveled beyond the breast, but cannot yet be detected on available imaging studies. Micrometastases is a term you may hear that describes metastases that could be present but cannot yet be detected on scans.
     
  • Neoadjuvant chemotherapy: Chemotherapy may be given before surgery to shrink a tumor enough so that surgery is possible. For example, neoadjuvant chemotherapy may be given to someone who has an inoperable lung cancer in order to decrease the size of the cancer so that surgery is possible. 
     
  • To extend life: Chemotherapy is often used with solid tumors in order to increase life expectancy, but without the ability to cure a cancer. With a recurrent cancer or a cancer that has metastasized, a cure is not usually possible, but chemotherapy may increase overall survival or the time until a tumor progresses (progression-free survival).
     
  • Maintenance chemotherapy: After initial treatment with chemotherapy, maintenance chemotherapy may sometimes be given either to help maintain remission of cancer or to prevent a cancer that is present from growing. With maintenance therapies, the doses of drugs used are often less than those given during initial chemotherapy.
     
  • Palliative therapy: Chemotherapy may also be given as a palliative treatment (palliative chemotherapy). In this setting, chemotherapy is used to reduce the symptoms caused by cancer, but not with an intent to cure the cancer. This is also sometimes referred to as 'salvage chemotherapy.'

    How Is Chemotherapy Given?

    Chemotherapy may be given in several different ways depending on the particular drug. Methods include:

    • Intravenous injection (IV): Many chemotherapy drugs are given intravenously. Most of these drugs are unable to be given orally as they would be broken down by digestive enzymes, or would be too toxic to the lining of the digestive tract. IV drugs may be given via either a peripheral IV or a central line (see choices below).
       
    • Intramuscular injection (IM): IM injections deliver the drug into a muscle, like a tetanus shot.
       
    • Subcutaneous injection (SubQ): SubQ injections are given with a small needle just beneath the skin, like a TB test.
       
    • Intrathecal injection: Intrathecal chemotherapy is an approach in which chemotherapy drugs are delivered directly into the cerebrospinal fluid (CSF) that bathes the brain and spinal cord. Many cancer drugs do not cross the blood-brain barrier—a  membrane surrounding the brain that limits its access to toxins. In order to treat cancer cells present in the brain, a needle is inserted directly into this space in a procedure similar to a spinal tap. Sometimes—similar to a central line in IV therapy—a reservoir is placed under the scalp (an Ommaya reservoir) to allow repeated intrathecal injections. Intrathecal chemotherapy may be used either to treat cancer that has spread to the CSF or to prevent cancer from spreading to the CSF.
       
    • Intraperitoneal injection: With intraperitoneal chemotherapy,chemotherapy agents are injected directly into the peritoneal cavity, the cavity that houses many of the abdominal organs.
       
    • Oral therapy: Some medications may be given as a pill, capsule, or liquid.

    A new and novel method of delivering chemotherapy drugs is via their attachment to drugs that can carry them directly to cancer cells.This type of immunotherapy, referred to as a conjugated monoclonal antibody therapy, consists of medications that include a combination of both a monoclonal antibody and chemotherapy drug. The monoclonal antibody serves to find and attach itself to specific cancer cells. One located, its "payload”—the chemotherapy drug—is  delivered directly to the cancer cell.

    Intravenous Chemotherapy: Peripheral IV vs. Port vs. PICC vs. Tunneled CVC

    One question you may face if you are having IV chemotherapy is whether to have these treatments through a peripheral IV—an IV placed in your arm or hand—or a through a central venous catheter (CVC).

    With a peripheral IV, your chemotherapy nurse will place an IV in your arm at the start of each infusion and remove it at the end. A central venous catheter is placed prior to beginning chemotherapy and is often left in place through the duration of treatments.There are risks and benefits of each of these methods, though sometimes a central line is mandatory (for example, with chemotherapy drugs that are very irritating to veins).

    There are three main types of central lines. A chemotherapy port, or port-o-cath, is a small plastic or metal receptacle that is placed underneath your skin, usually on your chest. Attached to this is a catheter that is threaded into a large vein near the top of your heart. These are inserted in the operating room under sterile conditions preferably a week or so before your first infusion. A port can spare you the repeated needle sticks of a peripheral IV and can also be used to draw blood and give transfusions. 

    A PICC line is inserted in a vein deep in your arm and can be used for one to six weeks in general. If your veins are damaged from chemotherapy, or too small for a PICC line to be placed, a tunneled CVC is a third option for some people. In this procedure, a catheter is tunneled under the skin, usually on your chest, and the catheter is threaded into a large vein as with a port or PICC line.

    How Often Is Chemotherapy Given?

    Chemotherapy is usually given over the course of several sessions, separated by a period of time (often two to three weeks). Since chemotherapy treats cells that are in the process of cell division, and cancer cells are all in different states of resting and dividing, repeated cycles allow a greater chance to treat as many cancer cells as possible. The amount of time between sessions will vary depending on the drugs, but is often scheduled at a time when your blood count is expected to have returned to normal.

    Combination Chemotherapy

    A combination of different chemotherapy drugs—referred to as combination chemotherapy—is usually used to treat cancer, rather than a single drug alone. There are several reasons for this. Cancer cells in a tumor are not all in the same place in the process of growth. Using drugs that affect the cell cycle at different points in multiplication and cell division increases the chance that as many cancer cells as possible will be treated. Using a combination of medications may also allow physicians to use of lower doses of several agents, rather than a higher dose of a single agent, thereby decreasing the toxicity of the therapy.

    Acronyms are often used to describe chemotherapy protocols. For example, BEACOPP is a seven-drug regimen used in the treatment of Hodgkin's lymphoma.

    Categories of Chemotherapy Drugs

    There are several categories or types of chemotherapy drugs, which vary both in how they work (mechanisms) and where they work (what part of the cell cycle.) Some drugs work on one of the four primary phases of cell division, whereas others—termed phase non-specific drugs—may work at multiple points. Some of these classes of drugs include:

    Alkylating Agents: This is the most commonly used class of chemotherapy drugs. They are non-specific drugs that directly damage DNA and are used to treat a wide variety of cancers. Examples include Cytoxan (cyclophosphamide) and Myleran (busulfan).

    Antimetabolites: Simplistically, these drugs work by pretending they are nutritional sources for the cell. Cancer cells take up these drugs instead of nutrients and essentially starve to death. Examples include Navelbine (vinorelbine), VP-16 (etoposide), and Gemzar (gemcitabine).

    Plant Alkaloids: This class includes drugs obtained from plant sources. Examples include Cosmegen (dactinomycin) and Mutamycin (mitomycin).

    Antitumor Antibiotics: Antitumor antibiotics differ from the types of antibiotics used to treat bacterial infections. These drugs work by preventing cancer cells from reproducing (and hence, keep tumors from growing).  Examples include Adriamycin (doxorubicin) and Cerubidine (daunorubicin).

    Why Doesn't Chemotherapy Always Cure Cancer?

    Since chemotherapy can often effectively decrease the size of a tumor, it can be confusing to try to understand why it doesn't usually cure cancers (solid tumors) that have spread. The problem is that cancer cells find ways to outsmart the drugs after a period of time. Oncologists refer to this as a tumor developing resistance. This is the reason why a different combination of chemotherapy drugs (second-line treatment) is often used if a cancer recurs or grows while on chemotherapy.

    Side Effects of Chemotherapy

    Many people are frightened about chemotherapy, having heard horror stories from the past. But just as advances have been made in other areas, improvements have been made in chemotherapy as well. Side effects still occur, but many of these can be managed very effectively. There are also several things you can do to add to your comfort at this time. 

    Keep in mind that everyone is different and responds to chemotherapy in a different way. Some people may have several of these side effects, while others may have none at all. The particular side effects you might expect will depend on the specific medications you receive, but some of the most common include:

    • Nausea and Vomiting: Nausea and vomiting are perhaps the most feared side effects of chemotherapy, but both prevention and treatment of these symptoms have improved dramatically in recent years. Anti-nausea drugs (antiemetics) are frequently given right along with many of the chemotherapy drugs to prevent nausea.

      Both medications and lifestyle factors can help with chemotherapy-induced nausea and vomiting. Taking a few moments to consider the food you eat is important, and we are learning more and more about the importance of good nutrition during cancer care. While many people have found using ginger and acupressure for chemotherapy-related nausea helpful, these alternative approaches should be used along with rather than instead of conventional anti-nausea treatments for the best results. Once nausea has developed, it can be much harder to play "catch up" than if the symptom is addressed right away.
       
    • Hair Loss: Hair loss is common with chemotherapy, and though it's not dangerous to your physical health, it can be very distressing emotionally. Not all chemotherapy drugs cause hair loss, but what surprises many people is that the chemotherapy drugs that cause hair loss usually cause more than the loss of hair on your head. From the top of your head, to your eyebrows and eyelashes, to pubic hair, preparing for hair loss on chemotherapy may help you cope a little easier with what's to come.

      Some people find it helpful to go wig and scarf shopping before they start treatment. Others find that "reframing" can add a little humor to this stressful time. Though having the "benefit" of not having to shave your face—or your legs for a woman—is stretching it a bit, humor has helped many people facing this common side effect.

      Hair loss commonly begins two to three weeks after your first treatment, with regrowth occurring rapidly after your final treatment. Hair loss may persist if you receive radiation to your head, but permanent hair loss is rare with chemotherapy alone. Researchers have looked into methods for preventing hair loss from chemotherapy with some mild success.The use of scalp cooling has been partially effective in some studies, though this can be very uncomfortable and carries a theoretical risk of reducing the effectiveness of treatment.
       
    • Bone Marrow Suppression: Suppression of the bone marrow is one of the more dangerous side effects of chemotherapy, but the management of this side effect—especially the risk of infections due to a low white blood cell count—has improved substantially in recent years. All of the blood cells (white blood cells, red blood cells, and platelets) are formed from stem cells in the bone marrow. Since these are very rapidly dividing cells, all of them can be reduced by chemotherapy. Your oncologist will check a complete blood count (CBC) prior to each chemotherapy infusion and monitor your levels closely. Take a moment to review these tips for lowering your risk of infection during chemotherapy.
       
    • Mouth Sores: Around 30 percent to 40 percent of people will experience chemotherapy-induced mouth sores during treatment, though some medications are more likely than others to cause this symptom. If you are receiving drugs likely to cause mouth sores, your chemotherapy nurse may encourage you to suck on an ice pop or ice chips while the drug is infused. These sores can be uncomfortable on their own, but can also predispose to secondary infections such as oral thrush

      A few dietary precautions can make a big difference in your comfort. Tips include avoiding citrus fruits, spicy and salty foods, and foods at extreme temperatures, and minimizing foods with sharp edges such as crackers. You may hear cancer survivors rave about "magic mouthwash" for mouth sores but, talk to your oncologist before using any preparation, prescription or otherwise.
       
    • Taste Changes: Taste changes, often referred to as "metal mouth," occur for half of people undergoing chemotherapy. While this symptom is most often just a nuisance, check out these tips for coping with chemotherapy-induced taste changes. Many people find these taste changes less bothersome if they add a touch of flavor to foods by marinating meats and using a variety of sauces (adding liquids to foods can also help with mouth sores). Sucking on mints or chewing gum, and switching to plastic utensils for a time, may also be helpful.
       
    • Peripheral Neuropathy: Tingling and pain in a stocking-glove distribution (hands and feet) are common symptoms related to chemotherapy-induced peripheral neuropathy and affects roughly a third of people receiving chemotherapy Some drugs, most notably "platinum" agents, are more likely to cause this side effect than others. Our nerves are lined with a substance called myelin that acts is a similar way to the outer covering of an electrical cord. It's thought that these drugs somehow damage the myelin and, in doing so, disrupt the normal processing of nerve signals.

      Unlike many of the symptoms associated with chemotherapy, neuropathy often persists well after chemotherapy has been completed, and can—at times—be permanent. Research into glutamine and other methods that might prevent neuropathy from occurring in the first place is ongoing. Talk to your doctor about these options before beginning chemotherapy.
       
    • Bowel Changes: Chemotherapy drugs can cause bowel changes ranging from constipation to diarrhea, depending on the drug. Constipation is common with some of the drugs used to prevent nausea, and your doctor may recommend measures for preventing constipation during chemotherapy, such as a stool softener, laxative, or both. Diarrhea can quickly become a problem for people on chemotherapy, especially as it contributes to dehydration. Check out these best foods for diarrhea from chemotherapy, but make sure to talk to your doctor promptly if you develop diarrhea.
       
    • Sun Sensitivity: Many chemotherapy drugs increase your chance of getting a sunburn when you go out in the sun, something referred to as chemotherapy-induced phototoxicity. Ask your doctor if the drugs you will receive place you at risk and what precautions you should take. (Note: Sunscreen alone may not be effective and may irritate your skin, especially if you are also receiving radiation therapy.)
       
    • Chemobrain: The term chemobrain has been coined to describe the cognitive effects some people experience during and after chemotherapy. Symptoms ranging from increased forgetfulness to difficulty with multitasking can be frustrating, and it can help for family members to be aware of this potential side effect. Some people find that keeping their brain active with exercises such as crossword puzzles, sudoku, or whatever "brain teasers" they enjoy can be helpful in the days and weeks following treatments.
       
    • Fatigue: Fatigue is the most common side effect of chemotherapy, affecting nearly everyone who receives these treatments. Unfortunately, this kind of fatigue isn't the type of tiredness that responds to a cup of coffee or a good night of sleep. There are a number of things that may help you cope with cancer fatigue, but the most important one is to allow yourself the extra time you need for rest. The best "treatments" for this side effect are to reach out to family and friends and allow them to help you. The saying "it takes a village" is nowhere as fitting as in the setting of chemotherapy.

    Long-Term Side Effects of Chemotherapy

    The long-term side effects of chemotherapy are not usually your first concern when you hear you need chemotherapy for cancer. With all cancer treatments, the benefits of treatment need to be weighed against the possible risks. Still, it's important to be aware of some of the late side effects— side effects that may not occur until months or even years after completion of cancer treatment. As with the short-term side effects, the odds that you will experience these symptoms will depend on the particular chemotherapy drugs you receive. Some late effects include:

    • Heart Disease: Some chemotherapy drugs, especially drugs such as Adriamycin (doxorubicin), can cause heart damage. The type of damage may range from heart failure to valve problems to coronary artery disease. If you are receiving any of these drugs, your doctor may recommend a heart test before you begin treatment. Radiation therapy to the chest may also increase the risk of heart-related problems.
       
    • Infertility: Many chemotherapy drugs result in infertility after treatment. If there is a chance you would like to conceive after chemotherapy, options such as freezing sperm or freezing embryos have been used successfully by many people. Make sure to have this discussion before starting treatment.
       
    • Peripheral Neuropathy: The tingling, numbness, and pain in your feet and hands caused by some chemotherapy agents may persist for many months, or may even be permanent, As noted, research is being done to look for ways to not only treat this side effect but prevent it from occurring altogether.
       
    • Secondary CancersSince some chemotherapy drugs work by causing DNA damage in cells, they may not only treat cancer but predispose someone to developing cancer as well. An example of this is the development of leukemia in people who have been treated with Cytoxan (cyclophosphamide), a drug commonly used in breast cancer treatment. These cancers often occur five to 10 years or more after chemotherapy has been completed.

    Other possible late effects may include symptoms ranging from hearing loss or cataracts to lung fibrosis. Though the risk of these adverse reactions usually pales in comparison to the benefit of treatment, take a moment to talk with your doctor about side effects that may be unique to your particular chemotherapy regimen.

    Questions to Ask About Chemotherapy

    Having a list of questions on hand when you see your doctor increases the chance that you'll understand your treatment as well as possible. Consider the following questions, and add your own that come to mind:

    • What is the purpose of the chemotherapy you will be receiving? In other words, is the goal to cure your cancer, to extend your life, to address the possibility that cancer cells have spread after surgery, or to reduce symptoms?
    • What specific chemotherapy drugs will you be receiving? How will these drugs be given? Do you recommend a port or a PICC line, or is a peripheral IV OK?
    • How much will the treatment cost?
    • Where will you receive your chemotherapy?
    • How often will you have infusions, and how many sessions will be needed?
    • How long which each session last?
    • How will chemo affect your day-to-day life, ability to work, and ability to care for your children?
    • Is it OK to go alone, or do you need a friend to drive you?
    • What are the more common side effects of this treatment, and what is done to manage each of these? When would these be expected to begin, and when do they usually go away? Are there any common late effects of this treatment?
    • If peripheral neuropathy is a potential side effect, is there anything that can be done preventively to lower the risk?
    • Is it likely that you will lose your hair? (Many insurance companies pay for a wig but require a prescription from your oncologist. The prescription should be written for a "hair prosthesis" or a "cranial prosthesis" in order to be covered.)
    • What side effects should prompt you to call right away? In other words, what possible emergencies could occur?
    • If you are interested in having children in the future, how will chemo affect your fertility and what measures can you take to preserve your ability to have children? 
    • How often will your blood counts be checked? What should the numbers be before your next session? What will happen if your counts are too low?
    • Will you need to take medications after you go home, such as laxatives to prevent constipation or injections that stimulate your white blood cells?
    • Will you need to take any special precautions? For example, will you need to stay away from people who are sick, be careful in the sun, avoid changing the litter box, or wear a mask in public? 
    • For premenopausal women, do you need to use birth control?
    • Should you take any vitamin or nutritional supplements during chemotherapy? (Chemotherapy could predispose you to vitamin deficiencies, but some vitamin and mineral supplements may interfere with chemotherapy.)
    • Are there any immunizations you need? (This information about immunizations for people with cancer discusses both immunizations that may be recommended and vaccines which should be avoided during cancer treatment.)
    • What alternative or complementary therapies (integrative treatments for cancer) may help ease the symptoms of chemotherapy? Are these available at your cancer center?
    • Are there any clinical trials available that may be more effective than the regimen that's recommended?
    • How (and when) will you know if the chemotherapy drugs are working?
    • What is your "plan B" if chemotherapy is not effective? 
    • Who should you call if you have any concerns, either day or night?

    Practical Matters

    Most of us lead busy lives before a diagnosis of cancer. Learning you will need chemotherapy may have you wondering how you will ever manage your "normal" commitments and obligations along with your treatment. Take a moment to consider these practical matters and think about what help you will need to keep your life running smoothly. Do you need rides to your cancer center? Do you need help with childcare? Here are few tips to help you prepare:

    • Choose a good friend or two who can be your "coordinators" when it comes to errands and communicating to others.These people can help coordinate the efforts of friends who have offered to help, and act as spokespersons when you really don't want to answer the phone yet again. Many people start a site on Caring Bridge or a similar site where they can share updates on how treatment is going. These sites can also be a tremendous source of encouragement and allows friends to send their love without worrying about disturbing you. Sites such as Lotsa Helping Hands can be invaluable in organizing tasks among those who have volunteered to help. Whether it is preparing a meal to deliver to you, helping with housework, or providing childcare, people can sign up for dates and times to offer their assistance.
    • You will likely spend a significant amount of time sitting during your infusion sessions. Check out these tips on what to pack for chemotherapy for ideas on the best items to bring for your comfort and to prevent boredom. 

    For Friends and Family

    As your loved one begins chemotherapy, you may be feeling helpless, wondering what you can possibly do to help. Whether it's helping to prepare frozen meals or mowing the lawn, consider your talents and ways that you would most enjoy making that person's life during chemo flow as well as possible. Bear in mind that emotions can span the spectrum when someone is diagnosed with cancer. Practice patience and try not to take it personally if your loved one is less than considerate at times. Most of us are not our usual polite selves when we are tired, anxious, or in pain.

    Here are a few tips for supporting a loved one with cancer, but most important is simply being there. One of the greatest fears of people with cancer is being alone.

    A Word From Verywell

    If chemotherapy has been recommended as a treatment for your cancer, you're likely feeling anxious. It's hard to avoid hearing the horror stories of days gone by. You may need to remind yourself that positive advances have taken place in cancer treatment. Certainly, there are side effects, but improvements in the management of these have come a long way. Ask questions. Learn as much as you can about your diagnosis, and be your own advocate in your cancer care.

    Cancer can be an emotional roller coaster. Choose a few friends who you can share your feelings with openly and honestly. You don't always have to have to keep a positive attitude with cancer. In fact, it's important to honor yourself by expressing those not-so-positive emotions. Seek out those friends who listen without judgment, calm your spirit, and help you find humor amidst the stress.

    Chemotherapy can be difficult, but it can also be a special time. Many people look back on their chemotherapy days nostalgically, as they remember this time of connection with loved ones—a time when deep feelings flowed more naturally. Cancer treatments may drag you down a bit, but cancer often changes people in good ways too. Keep an eye open for those silver linings that shine through the cloud of cancer.

    Sources:

    American Society of Clinical Oncology. Cancer.Net. Understanding Chemotherapy. Updated 08/2015. http://www.cancer.net/navigating-cancer-care/how-cancer-treated/chemotherapy/understanding-chemotherapy

    Longo, D. L. Harrison's principles of internal medicine. 2013. New York: McGraw-Hill.

    National Cancer Institute. SEER Training Manual. Types of Chemotherapy Drugs. Accessed 08/16/16. http://training.seer.cancer.gov/treatment/chemotherapy/types.html

    Niederhuber, J., Armitage, J., Doroshow, J., Kastan, M., and J. Tepper. Abeloff's Clinical Oncology: 5th Edition. 2013. Philadelphia: Churchill Livingstone/Elsevier.

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