Article authored by Dr Sudeep Gupta with input from his colleagues from Department of Medical Oncology
Director ACTREC (Advanced Center for Treatment, Research and Education in Cancer) Professor of Medical Oncology, Past Convener, Gynecologic & Breast Oncology Working Groups Tata Memorial Center / Hospital & Homi Bhabha National Institute
This list contains answers to some of the most frequently asked questions by patients undergoing chemotherapy. Please go through this information carefully and ask your doctor about anything that you find difficult to understand. It should be noted that the facts mentioned below are general in nature; some variations are to be expected in each patient.
1. What is chemotherapy? How it is given?
Chemotherapy refers to certain drugs, which can inhibit or kill cancer cells. It can be given in the form of injections or oral medication. The majority of injectable chemotherapy drugs are administered through the intravenous route – either as bolus injections or as infusions lasting minutes to hours. However, some injectable chemotherapy agents are given through intramuscular (in the muscle), subcutaneous (beneath the skin) or intrathecal (in the spinal fluid) routes. Chemotherapy is usually administered in ‘cycles” – respectively every few weeks. Each “cycle” is given over one or several days. The cycle duration (time interval between two cycles, counting from the 1st day of initial cycle) and number of cycles varies between different tumours and different regimens. Chemotherapy is administered in several sessions with rest period inbetween so that you recover from the side effects. Chemotherapy session and rest period make one cycle.
The majority of solid tumours (e.g. lung, Breast, Ovarian, Gastrointestinal and other similar tumours) are treated with 4 to 8 cycles (average 6) of chemotherapy administered every 3 to 4 weeks. Some tumours can be appropriately treated with one of many regimens available. The treatment is usually tailor-made for each patient considering their unique condition and may be different from standard published protocols or scientific information.
Chemotherapy can be given in different ways depending on the type of your cancer and the treatment plan.
- By injection or a drip directly into a vein (intravenous)
- By mouth as tables or capsules (oral chemotherapy)
- By injection into muscle (intra muscular)
- By injection under the skin (subcutaneous)
- By injection into the fluid around brain and spine (intrathecal)
- Directly into body cavity, for example bladder (intracavity)
- Directly to the skin as a cream for some skin cancers
Methods of administering chemotherapy
- In the vein through a cannula – a short thin tube put at the back of your hand a lower arm.
- Central lines – a long thin hollow tube that is inserted in to a vein in your chest.
- PICC (Peripherally Inserted Central Venous Catheter) – a long thin hollow tube put into the vein near in your elbow.
- Implantable ports – a thin soft plastic tube with a rubber disc (port) at the end. It is put under a general local anesthesia
- PICC lines & implantable ports can be left in until your course of chemotherapy is over. You can go home with the line or port in.
- Possible problems with central line
- Infection, swelling, redness or pain
- Discolored fluid discharge from the exit site
- High temperature, fever
- Blood clots
- Tightness in the chest
2. What is the purpose of chemotherapy treatment?
The aim of giving chemotherapy depends on the stage of cancer being treated. In early stage disease it is given to prevent relapse. In advanced stage, the purpose is to control symptoms, improve the quality of life and in many instances improve survival. The majority of solid tumours are treated with some combination of surgery, radiation and chemotherapy. The majority of hematological (blood) cancers are primarily treated with chemotherapy or without radiation.
When is chemotherapy used?
- Main treatment for cancer
- In high doses as a part of stem cell transplant
- Before surgery or radiation therapy to shrink the cancer
- After the surgery and radiation therapy to reduce the risk of recurrence
- At the same time as radiation (called chemo radiation)
- To treat cancer that has spread
3. What tests are required before the 1st cycle of chemotherapy?
What tests are needed before subsequent cycles?
Depending on the investigations already performed by you may be required to undergo some or all of the following tests before starting the 1st cycle of chemotherapy: Complete blood count (CBC), Biochemistry (Liver and Kidney function tests, Tumour marker etc., all done but taking blood samples), Radiology (X-ray, CT Scan, ultrasound), Biopsy etc. You may be called between two cycles for some blood tests (called mid-cycle evaluation) to check the effect of the preceding cycle of chemotherapy. In the majority of instances you will be advised to undergo blood tests (typically CBC, but sometimes other biochemical tests) prior to each cycle or chemotherapy. This is important because blood counts need to recover to normal before the next cycle can be administered. Depending in your specific case the doctor may evaluate the tumour response after a few cycles of chemotherapy will X-rays, CT Scans and other tests.
4. Do I need to be admitted to the hospital for chemotherapy? What is ‘Day care’?
Depending on the type of chemotherapy planned and the general condition of the patient, hospitalization may or may not be required. Many chemotherapy regimens are administered as intravenous infusion lasting several hours over one or more days. These can often be safely administered in “Day Care” where you are admitted for a short duration every day and then discharged. If day care chemotherapy is decided for you, an appointment should be sought from the day care staff for each cycle. You are expected to report to the day care at the appointed time and day. The day care is located on the 5th floor, Main Building, for private category patients and on the 3rd Floor, Golden Jubilee Block, for general Category.
Some chemotherapy regimens can be safely administered as intravenous push (bolus) in the injection room.
5. It is guaranteed that I will be cured if I take chemotherapy as prescribed?
The answer to this question is, unfortunately, No. The nature of cancer is such that there is always some chance of relapse (disease coming back) after apparent initial eradication. The chance of relapse varies from one patient to the other and depends on the type of tumour, its stage, the adequacy of treatment and many other factors. In advanced stages also, in only a fraction of patients (not all) the cancer will respond to chemotherapy. It is important to appreciate that statistics are applicable only to a large group of patients. For an individual like you the outcome is unique. For e.g. when your doctor tells you that the 5-year cure rate is 80%, what he means is this: if 100 patients like you are treated today and followed up, at the end of 5 years 80 will be alive and free of their disease. The other 20 will be experience recurrence at some point of time in the period. It is often very difficult or impossible to predict which group an individual patient will fall into also when and also when and if recurrence of cancer will happen.
6. What is the total cost of chemotherapy in my case?
The cost of chemotherapy is variable and depends on the type of cancer, the specific chemotherapy regimen chosen and the degree of supportive care that each patient requires. The expense of full chemotherapy course includes the cost of chemotherapy drugs, supportive medicines and hospitalization. You must understand that the cost prediction is approximate and unforeseen circumstances may lead to overruns. Please ask your doctor about the total cost of chemotherapy in your case.
It is to be noted that the cost of chemotherapy drugs has no correlation with their efficacy. More expensive drugs are not necessarily more effective and vice versa.
7. I live outside Mumbai. Can I take the 1st cycle in Tata Memorial Hospital and subsequent ones in my native place?
Yes indeed you can take the 1st cycle here and will give a letter of suggestion for the subsequent cycles at your native place. However if you decide on this course of action, you will be required to stay in Mumbai for 1 to 2 weeks after the 1st cycle to enable us to monitor side effects. Please don’t insist on leaving Mumbai immediately after the 1st cycle. When you come for follow up after completion of chemotherapy outside, please bring the exact dates of each cycle and any other interventions (surgery, radiation etc) that may have been carried out. You should note that the letters given for chemotherapy outside are only suggestions to your treating doctor. The safe and appropriate administration of chemotherapy is entirely the responsibility of your local doctor.
In a few instances the instances the planed chemotherapy is complicated and/or has high incidence of severe toxicity. Such regimens are best administered under the supervision of experienced oncologists and we may not be able to give you letters for outside chemotherapy I these cases.
8. What will the effect of chemotherapy on my fertility? What about contraception?
In general it is safe for patients to continue sexual relations with their partners during their treatment. However it is imperative that patients in reproductive age group practice contraception (preferably barrier method) throughout their treatment. Some chemotherapy drugs can cause temporary or permanent infertility .it this is of concern to you then please discuss this issue with your doctor. It you plan to have children after chemotherapy you are advised to discuss the recommended timing with your doctor.
In women of reproductive age group menses can temporarily or permanently cease after some types of chemotherapy.
9. It is my disease contagious? Can I transmit this disease to others by close contact? Can I play with children?
Cancer is not a contagious disease and there is no bar on maintaining normal contacts with other persons including children. This disease is not transmitted from one person to the other by close contact including sharing utensils, clothes, food, drinks and sexual activity.
10. I have long-standing diabetes and hypertension. Can I continue the medication for these disorders? Can I take medicines prescribed by the other doctors?
Yes you should continue the medications for chronic disorders like diabetes and hypertension. However you are urged to tell your oncologist about all the medications that you are taking. You can also take medicines prescribed by other doctors for emergency situations; you should tell them about your cancer treatment when you report to them.
11. I want to try Homeopathic treatment along with the treatment prescribed here. Can I do so?
You are advised against simultaneously taking medicines advised under alternative systems of medicine (Homeopathy, Ayurveda, Unani etc) with our treatment. Since we are not trained under those systems, we will not be able to predict and anticipate any adverse drug interactions that may occur. It you wish to discontinue our treatment and start another form of treatment you are at liberty to do so.
12. Can I seek a second opinion from another oncologist?
You are welcome to seek opinion from any number of doctors.
13. Can I continue to smoke? Can I continue to chew tobacco?
You are strongly to discontinue tobacco use in any form including smoking. Your relatives and friends are urged to stop tobacco use in any form since it is the single most important preventable cause of cancer related deaths I the population. It you or anyone known to you wishes to seek help with tobacco you can approach us.
14. What are the recommendations regarding food during my treatment?
The single most important recommendation regarding food and drinks is that they should be clean. It is ideal for you to have well-cooked food, served fresh and warm, during the entire period of your treatment. It is suggested that you avoid very spicy food. There is no bar on consumption of non- vegetarian dishes that are well cooked. You may also have fruits, which are carefully washed with clean water. Fruit juices have no special nutritive value over the corresponding fruits and because they can be a source of infection, they are best avoided during chemotherapy. It is suggested that you should consume clean water in liberal quantities (unless specifically instructed not to do so) throughout your treatment. You should wash your hands with soap and water before each meal and the person serving you food should do the same. This is one of the most important measures to prevent infection during chemotherapy. Unhygienic food and beverages (e.g. fruit juices & coconut water from road-side vendors, raw salad at restaurants etc) consumed during the period of chemotherapy is an important cause of diarrhea and other infections.
15. I have heard that chemotherapy is a very toxic form of treatment. I am scared to take chemotherapy. What should I do?
Like any other treatment modality chemotherapy does have side effects which can occasionally be severe. The occurrence and severity of each of the under mentioned side effects vary from one individual to the other and also on the specific chemotherapy regimen used. It is important to understand that all side effects don’t occur in all patients. In fact the majority of patients are able to complete their prescribed chemotherapy course without major compliments. The purpose of acquainting you with this information is to enable you to anticipate (and to some extend prevent complications). We hope this ensure better partnership between you and your medical team in your treatment. Therefore please don’t be alarmed after reading the subsequent of potential side effects and complications of chemotherapy.
It should also be noted that all new symptoms that occur during chemotherapy may not be caused by the latter; other factors like progression of underlying tumour may be operative.
The final decision to give you chemotherapy is suggested only if the benefits outweigh the risks.
16. What are the common side effects of the chemotherapy?
The relatively common side effects and toxicities of chemotherapy include, but are not restricted to the following:
a) Nausea and / or vomiting: They may startimmediately after chemotherapy or occur several days later. These effects last for a variable period of time (hours to weeks). Some drugs like cisplatin have a high propensity to cause nausea and vomiting. Medications (called anti-emetics) will be given to you to decrease the incidence & intensity of nausea and vomiting after chemotherapy. Anti-emetics may be prescribed to you in oral and / or injectable forms.
b) Sores and ulcers in the mouth and throat: These effects typically start few days after the start of chemotherapy. It is suggested that you should maintain good oral hygiene using a soft toothbrush twice a day. You should also use antiseptic mouth washes (e.g. Hexidine, Povidone-iodine etc. 2-3 times a day throughout your chemotherapy. To relive mouth pain (in case you do develop ulcers) you may use Xylocaine viscous (to be liberally applied to mouth before every meal).
c) Diarrhea: This may develop at any time after the start of chemotherapy and is usually due to one of the two reasons. First, the chemotherapy drug may affect the cells lining the intestinal epithelium and cause ulceration. Second, it may be due to unhygienic food (e.g. fruit juices & coconut water from road side vendors, raw salads in restaurants etc.) consumed during the period of chemotherapy.
d) Constipation: This is usually a side effect of anti-emetics prescribed with the chemotherapy drugs. However it may also be due to chemotherapy drugs themselves or the underlying disease. You make take Isapgol Husk (Naturolax or Softvac powder) 4-6 tsf with water at bedtime for a few days beginning with each cycle of chemotherapy.
e) Hair loss: You might have partial or complete hair loss during treatment. There is no proven effective measure to prevent these side-effects. You will regain the hair within 4-6 months of completions of chemotherapy.
f) Skin Toxicity: Many drugs can cause darkeningof the skin particularly in the light exposed parts of the body. Some drugs can also cause darkening of the nail beds. These side effects are at least partially reversible after the completion of chemotherapy.
g) Pain and aches in limbs and other parts of the body: Certaindrugs like paclitaxel can cause significant pain in limbs, bones and other body parts. This usually starts within a few hours after starting the drug and lasts for up a few days. Pain-killers can be prescribed by your doctor to overcome this effect.
h) Low white blood cell counts (leukopenia) with or without infection: This complication usually starts about 6 to 7 days after start of chemotherapy and lasts for a variable period of time (usually few days). This side effect of chemotherapy occurs in a somewhat predictable, dose and regimen dependent manner. Low WBC counts may or may not be associated with infection. The first sign of infection is usually fever (≥ 100 F) although some patients can develop serve infection without fever. The other common indications of infections are chills, swelling, loose motions, sore throat, cough, burning during urination, redness or swelling in the skin or in the genital area, unusual vaginal discharge or swelling, etc. These are several measures which can help you to lower the risk of infections. You must follow the instruction regarding diet given below. Stay away from people who have cold, flu, boils etc. Avoid crowds. Stay away from children’s who have been recently immunized. Despite these precautions some patients will develop infection. In the vast majority of patients, infection can be controlled with either oral or injectable antibiotics if it is diagnosed and treated early. In a very small fraction of patients it may be fatal. You must report to the hospital as early as possible if you develop fever or other signs of infection after the administration of chemotherapy. Your doctor may call you to check your blood counts after the 1st or subsequent cycles of chemotherapy. The risk of developing low blood counts is not altered by any specific food items.
i) Low platelet counts: This can develop at a variable time after the administration of chemotherapy (usually in the 2nd week) and last from a few days to several weeks. Platelet count is important because the chance of spontaneous bleeding (for e.g. from nose, gums, skin, or vomiting or stools) increase with low platelet count particularly when it falls below 20000/Mm3 or when accompanied by fever. The most significant site of bleeding is brain, which can lead to altered consciousness and other manifestations. It is suggested that you should not take any medications without asking your doctor, prevent cuts during shaving and /or using scissors and avoid strenuous physical activity that may lead to injury. Platelet transfusions may be required (as decided by your doctor) in some patients.
j) Anemia: This refers to low hemoglobin levels I the blood and is a well-documented side effect of many chemotherapy drugs. This is often a cumulative effect i.e. in has a higher propensity to occur after several cycles of chemotherapy. These are several other factors that may contribute to the development of anemia. For e.g. bleeding, heavy or prolonged menses, pre-existing malnutrition, poor food intake etc. It manifests as malaise, weakness, fatigue, palpitations, shortness of breath, poor concentration etc. Your doctor may decide to give you packed RBC transfusions to treat this condition or you may require certain medications.
17. What are the less side effects of the chemotherapy?
The relatively uncommon toxicities that may result due to chemotherapy are as follows:
a) (Extravasation – another word) of the chemotherapydrug can cause pain, swelling and ulceration at the side of injection. Please contact your doctor IMMEDIATELY if you develop any of these symptoms.
b) Hypersensitivity and anaphylaxis: Thisusually manifests as a varying combinations of urticarial (a type of skin eruption), shortness of breath, chest tightness, palpitations, sweating and a sinking feeling within a short time (minutes to hours) after starting chemotherapy. The treatment is immediate cessation of the chemotherapeutic drug and other supportive medications. It is an uncommon but potentially serious complication of chemotherapy and is unpredictable. It can happen due to any drug although some like paclitaxel, rituximab etc. have higher propensity to cause hypersensitivity. This type of reaction can occur after those first or subsequent cycles of chemotherapy. Any prior history of allergy should be reported to your doctor.
c) Heart (cardiac) Toxicity: Some chemotherapy drugs like doxorubicin, epirubicin, daunorubicin, idarubicin, mitoxantrone, 5-fkurouracil, Herceptin etc. can cause cardiac toxicity in the form of arrhythmias (irregular cardiac rhythm) or heart failure. This may happen from minutes to years after the administration of chemotherapy. The occurrence of this complication is low and the existences of pre-existing heart disease.
d) Kidney (Renal) Toxicity: Patients undergoing chemotherapy are prone renal toxicity for a variety of reasons. Certain tumors (for e.g. some lymphomas and leukemia’s) can lyse rapidly after chemotherapy, leading to clogging of kidneys and failure. Some chemotherapy drugs like cisplatin and antibiotics like amikacin can cause direct injury to kidneys. With appropriate precautions like adequate hydration, urinary alkalization and allopurinol, this complication can be prevented to some extent.
e) Lung (respiratory) Toxicity: Patients undergoing chemotherapy are prone to develop upper or lower respiratory tract infections due to impaired immunity. These manifest as cough, chest pain and shortness of breath. In addition to this, some chemotherapy drugs (most notably bleomycin) can cause direct injury to lung, presenting as cough, shortness of breath and infiltrates on chest X-ray. You must report any of these symptoms to your doctor at the earliest.
f) Neurotoxity: Some chemotherapy drugs can cause direct injury to peripheral nerves manifesting as tingling, nunbness, and weakness of muscles and occasionally as constipation. The most commonly implicated drugs are vincristine, cisplatin and paclitaxel. These effects are partially reversible after further exposure to the drug is stopped. In addition to this, other drugs like ifosfamide and high-dose cytosine arabinoside can cause central nervous system toxicity presenting as altered consciousness. Some drugs like cisplatin can cause hearing impairment particularly for high frequencies. This is often related to the cumulative dose of the drug.
g) Liver (Hepatic) toxicity: very occasionally chemotherapy drugs or antibiotics can cause toxicity to the liver, which can present as loss of appetite, jaundice and / or impairment of liver function tests. More commonly these abnormalities are due to involvement of the liver by the underlying cancer.
- Keep clean and always wash your hand thoroughly after using the toilet or before preparing the food.
- Stay away from crowded places and people who you know have an infection, cold etc.
- Make sure that your food is thoroughly cooked
- Tell your doctor if you have nosebleeds, bleeding gums or any rash
- Wear protective gloves when doing work
- Use a soft toothbrush to protect your gums from bleeding