Guidelines For Managing the Side Effects of Chemotherapy

Cancer Services, Royal North Shore Hospital, updated October 04

Contents
Chemotherapy.........................................................................................................................3 Infections.................................................................................................................................4 Preventing Infections......................................................................................................4 Bleeding .................................................................................................................................5 Avoiding Bleeding Problems..........................................................................................6 Anaemia..................................................................................................................................6 Signs and Symptoms of Anaemia...................................................................................6 Self elp !reatments.......................................................................................................6 "o#th Care..............................................................................................................................$ S#ggestions to Prevent a Sore "o#th.............................................................................$ !reatment for a Sore "o#th% &lcers or Infections..........................................................$ elpf#l ints for !reating a Sore "o#th'.......................................................................$ Avoid'..............................................................................................................................$ Pain (elief'......................................................................................................................) *a#sea and +omiting..............................................................................................................) !he ,r#gs "ost Commonly &sed Incl#de'....................................................................) Side -ffects of Anti.na#sea "edications .......................................................................) Prevention of *a#sea and +omiting...............................................................................) /ther 0ays to Prevent *a#sea and +omiting................................................................1 Bo2el Care..............................................................................................................................1 ,iarrhoea.............................................................................................................................1 !reatment of ,iarrhoea...................................................................................................1 Constipation......................................................................................................................34 Prevention.....................................................................................................................34 *#trition................................................................................................................................34 S5in.......................................................................................................................................34 6atig#e7!iredness..................................................................................................................33 Prevention of 6atig#e'...................................................................................................33 air 8oss...............................................................................................................................33 S#ggestions for caring for yo#r scalp and hair'............................................................39 6ertility7Se:#ality..................................................................................................................39 -:cretion of Chemotherapy..................................................................................................33 S#pport Services at (*S ....................................................................................................34 ;eneral Services............................................................................................................35 Bibliography .........................................................................................................................35

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Chemotherapy
Chemotherapy is given to destroy cancer cells. It is given at regular intervals to try and stop the cancer from spreading. Most chemotherapy has some side effects, which you may or may not experience. This booklet will explain how to prevent and manage the most common chemotherapy side effects. If you have any questions that are not explained in this booklet, it is important to ask your doctor, pharmacist or chemotherapy sister. urther information is also available from both the Cancer Council and the !eukaemia oundation.

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Infections
"ome chemotherapy can affect your bone marrow#s ability to produce white blood cells. $hite blood cells help you fight infections, therefore if they are low you are more likely to pick up infections. % low white cell count is called neutropenia. &our white cell count is usually lowest ' to () days after chemotherapy, and may take * to ) weeks to recover. +egular blood tests will be done to monitor your white cell count. &our doctor,nurse will tell you how often this needs to be done. If these counts drop excessively, your treatment may be postponed or your dose of chemotherapy may be reduced. -ne of the signs of an infection is an elevated temperature. Therefore you will need to buy a thermometer to monitor this. &our doctor,nurse will advise you how often you will need to take your temperature.

You will need to go to the Emergency Department of your hospital without delay if you experience a temperature over ! C" or chills and rigors #a violent attac$ of shivering%" Contact your doctor&health care wor$er if any of the following symptoms of infection occur' .i//iness. "weating. Mouth ulcers, red or bleeding gums. "ore throat. "evere cough. 0urning or stinging when you pass urine, or passing urine more frequently. .iarrhoea 1this can also be a side effect of chemotherapy2. 3nusual vaginal discharge or itching. +edness, swelling or tenderness especially around a wound, sore, pimple, intravenous in4ection site, portacath, hickman catheter or 5ICC line. (reventing Infections $ash your hands with soap frequently through the day,1preferably from a pump pack2. It is especially important to wash them before eating and after using the bathroom. Clean your rectal area gently and thoroughly after each bowel movement, wiping from front to back.

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 3se "odium 0icarbonate 1or similar2 mouthwash, at least four times

a day, after meals and at bedtime 1see 6Mouth Care7 page '2. %void people with colds, flu, measles or chickenpox. %void crowds ie. shopping centres, cinemas and public transport. 3se a soft toothbrush. .on#t squee/e or scratch pimples. 5at your skin dry after your daily shower8don#t rub. 3se a simple moisturiser 1eg. "orbolene 9 :lycerin2 to soften and protect your skin. ;eep cuts and gra/es clean. $ear gloves when gardening or cleaning up after pets. %void takeaway food, raw fish, soft cheese and salami. $ash all fruit and vegetables before eating. .o not have any vaccinations, dental work or surgery done without first checking with your doctor 1you may need antibiotic cover with this2. .o not use suppositories or enemas while your white cell count is low. .o not use tampons while your white cell count is low.

)leeding
"ome chemotherapy can reduce your bone marrow#s ability to produce platelets. 5latelets help stop bleeding. % low platelet count is called thrombocytopenia. &our platelet count is usually lowest ( to ) weeks after chemotherapy, depending on your chemotherapy regime. +egular blood tests will be done to monitor your platelet count. &our doctor,nurse will tell you how often this needs to be done. If these counts drop excessively you may need a platelet transfusion, your treatment may be postponed or the dose of your chemotherapy may be reduced. Contact your treating doctor&health care wor$er immediately if you have any of the following symptoms' <asy bruising. .evelop small red spots under the skin. 5ass pink or red urine. 5ass black or bloody bowel movements =ave frequent nosebleeds. =ave a persistent headache. *eport to your doctor or the +ccident and Emergency Department at your nearest hospital if you have ,leeding that will not stop"

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+voiding )leeding (ro,lems .o not take any medications containing aspirin 1eg. %spro Clear, "olprin2 or anti8flammatory medications 1eg. >aprosyn, ?oltaren2 without first checking with your doctor. .o not use suppositories or enemas while your platelet count is low. 3se a soft toothbrush. .o not floss your teeth. 0low your nose gently. Take extra care not to cut yourself when using sharp instruments. %void contact sports and other activities that might result in in4ury. .o not have any vaccinations, dental work or surgery done without first checking with your doctor. 3se an electric shaver instead of a ra/or

+naemia
"ome chemotherapy can reduce your bone marrow#s ability to produce red blood cells or haemoglobin. % low haemoglobin count is called anaemia. %naemia usually occurs @ to A weeks after your first treatment, you may not notice these symptoms immediately. +egular blood tests will be done to monitor your haemoglobin count. %s red blood cells carry oxygen to all parts of your body, you may become tired and weak if this count is low. If your haemoglobin count falls too low you may require a blood transfusion. Signs and Symptoms of +naemia Tiredness and weakness. "hortness of breath. .i//iness. 5ale looking skin. "wollen ankles. Constipation. Self -elp .reatments !imit your activities and get plenty of rest. >aps during the day can help. %sk for help when you need it, especially with tasks such as shopping, housework, driving and gardening. <at a balanced diet.

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Mouth Care
"ome chemotherapy can cause a sore and ulcerated mouth. To prevent infections occurring and promote healing, it is important to keep your mouth clean during your treatment. Suggestions to (revent a Sore Mouth 3se a soft, small headed toothbrush which must be rinsed well after every use. :ently brush your teeth after each meal using circular strokes. 3se a mouthwash at least ) times a day. $e recommend a sodium bicarbonate or a saline 1common salt2 mouthwash. .issolve either (8 teaspoon of sodium bicarbonate powder or (8teaspoon of common salt in a glass of warm water. +inse your mouth well, then spit out. %void commercial mouthwashes that contain alcohol, as they will dry and irritate your gums. If you have dentures, remove and clean them after each meal. +inse your mouth with mouthwash when your dentures are out. .reatment for a Sore Mouth/ 0lcers or Infections Check your mouth every time you do your mouth care. If your mouth is sore to eat or drink, you have excess saliva or you develop a white coating on your tongue, use eitherB "odium 0icarbonate or saline mouthwash every C to ) hours or 0iotene mouth wash 1available from local chemist2.
&ou must also see your treating doctor and he,she will prescribe an

antifungal preparation. -elpful -ints for .reating a Sore Mouth' 0iotene toothpaste may help if other toothpastes irritate your gums. .rink plenty of fluids. "uck on ice and ice blocks. <at soft, bland moist foods. Chew sugarless chewing gum or suck sugarless lollies 1these stimulate the flow of saliva2. 3se lip balm if your lips become dry. +void' Mouth washes containing alcohol. "picy and salty food. %cidic foods 1grapefruit, oranges, lemons and tomatoes2. +ough, coarse or dry foods. =ot food. +.6reeman% /ncology C*C% (oyal *orth Shore ospital% 9444 $

(ain *elief' 3se Dylocaine viscous. "ip Emls slowly, or rub around your mouth. %void eating hot foods after using this 1you will need a script from your :52. or an individual ulcer use -rabase gel or Dylocaine CF 4elly 1from your 5harmacy2.

1ausea and 2omiting

In the past chemotherapy was associated with nausea, with or without vomiting. =owever with new and improved anti8nausea 1anti8emetic2 medications we are now generally able to prevent this occurring. %nti8 nausea medications are often given before and after chemotherapy. These can be given either orally, intravenously, intramuscularly 1not recommended for haematology patients2 or rectally as a suppository 1not recommended for haematology patients2. .he Drugs Most Commonly 0sed Include' Tropisetron 1>avoban2 -ndansetron 1Gofran2 .examethasone 1.ecadron2 .omperidone 1Motilium2 Metoclopramide 1Maxolon, 5ramin2 !ora/epam 1%tivan2 5rochlorpera/ine 1"temetil2 =aloperidol 1"erenace2 Side Effects of +nti3nausea Medications Common side effects include drowsiness, difficulty concentrating, headache and constipation. To prevent constipation 1caused by >avoban and Gofran2 it is necessary to take a laxative 1eg. Coloxyl with "enna2 while you are taking the tablets and for a few days afterwards. If you experience any difficulty with breathing, sweating, flushing, restlessness or twitching of the body you must stop taking the medication and contact your .octor immediately. (revention of 1ausea and 2omiting The anti8nausea medication you receive will depend upon the type and dosage of chemotherapy that you are given. It is important with chemotherapy that can cause severe nausea or vomiting that you take the anti8nausea medications regularly for at least one or two days after the chemotherapy finishes. &our pharmacist or chemotherapy nurse will advise you if this is necessary. Gofran and "temetil suppositories are available if you are unable to keep the tablets down 1>oteB .o not use suppositories if your platelet or white cell count is low2. &ou may experience anticipatory nausea 1feeling sick before the chemotherapy is given2. Taking %tivan tablets prior to the treatment and using relaxation techniques and music may help this. +.6reeman% /ncology C*C% (oyal *orth Shore ospital% 9444 )

4ther 5ays to (revent 1ausea and 2omiting <at small, frequent meals. <at and drink slowly. Try dry, salty crackers or toast, cold food 1eg. meats, sandwiches, salad2, as these are easier to manage. %void food with strong odours and cooking smells. It is important to drink plenty of fluid 1eg water, cordial, lemonade, ice blocks2. Try flat ginger beer or tea. +elaxation techniques may help. See your doctor or contact your nurse if you have severe nausea or vomiting which persists for longer than two days/ as you may ,ecome dehydrated" Signs of this include passing only small amounts of dar$ coloured urine and a dry tongue and mouth" 1)' 14. E2E*Y41E E6(E*IE1CES 1+0SE+ +1D&4* 24MI.I1G"

)owel Care
Diarrhoea
"ome chemotherapy may cause diarrhoea. If you are suffering from diarrhoea it is important to tell your doctor or your chemotherapy nurse as you may need intravenous fluids or your chemotherapy may need to be delayed. .reatment of Diarrhoea .rink plenty of fluids 1eg. water, cordial2. "ip small amounts frequently. "uck on water ice blocks. .o not drink fi//y drinks as they can cause gas and bloating. %void alcohol, coffee and large volumes of fluid at one time. %void high fibre foods 1eg. raw fruit, vegetables and cereals2, fatty meals, chocolate, dried fruits, beans, nuts and popcorn. <at small meals that have foods high in pectin 1eg. cooked peeled apples, bananas, avocados, rice and toast2. "top your laxatives if you are taking them. "ee your doctor. &ou may need a prescription for !omotil tablets or you can buy Imodium capsules from your local pharmacy.

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Constipation

"ome chemotherapy and cancer related drugs might cause constipation. This is more likely to occur if you are taking Morphine, Codeine, >avoban, Gofran, ?incristine, ?inblastine, ?indesine or ?inorelbine. (revention .rink plenty of fluids, C8* litres,day 1eg. water, prune 4uice and other fruit 4uices2. <xercise as able. Try to walk at least twice a week. <at high fibre foods. If your white blood cell count or platelets are low do not use suppositories or enemas. It is important to take your laxatives as prescribed. $e suggest Coloxyl with "enna, C tablets twice a day and Coloxyl (CH if needed. If you are still constipated try a "enokot milkshake after C daysB +ecipeB Mix (8C teaspoons of "enokot granules with (H8CH mls of %garol, 1available from your 5harmacy2. Mix into a paste with a little hot water. %dd milk and a scoop of ice cream. "hake well. This mixture tastes like a chocolate milkshake.
If constipation persists, consult with your nurse, pharmacist or

doctor.

1utrition
&ou may want to know what food will be helpful to you while you are receiving chemotherapy. It is important to eat as well as you can while undergoing treatment. If you eat a well balanced diet, with foods from the five basic food groups, you will cope with the side effects and fight infection better. Food and Cancer is a booklet produced by the >ew "outh $ales Cancer Council. This booklet will provide you with information on good nutrition, as well as answers for problems you may be experiencing with your diet. If you need further advice it is important that you tell your doctor or nurse so that a consultation can be arranged with a dietitian.

S$in

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&ou may have minor problems with your skin while you are having chemotherapy. These may includeB "usceptibility to sunburnB always wear factor *HI sunscreen, a hat and a long sleeve shirt when outside. .ry or itchy skinB use moisturi/ing cream 1eg. "orbolene and :lycerin cream2. %void long, hot showers or baths, perfume and after8shave lotion that contains alcohol. %cneB it is important to keep your skin clean and dry. &ou can use over the counter8medicated creams or soaps, avoid toners. $ear gloves to protect your hands and nails when gardening, washing dishes or performing other tasks around the house. If you develop a skin rash, contact your doctor or chemotherapy nurse. "ome chemotherapy can cause damage to the skin if it leaks out of the vein when it is being administered. Tell your doctor or chemotherapy sister if you have any burning, pain, redness, blistering or swelling around the needle site either during or after the treatment.

Fatigue&.iredness
Tiredness can occur because of both your chemotherapy and your illness. It is important to maintain a healthy lifestyle to reduce your fatigue and improve your quality of life. (revention of Fatigue' .on#t stay up late. Try to develop a routine sleeping pattern. .on#t sleep all day. <at a nutritious diet that limits caffeine and alcohol. =ave short frequent rest periods. Try alternative methods of relaxation 1eg. music, relaxation tapes2. <xercise as able eg. walk CH to *H minutes, C to * times a week. 5rioritise activities. .o the most important activities when you have the most energy. %sk for help with routine activities if you need to 1eg. shopping, cleaning and cooking2. If you are awake at night you may need mild sedation for a short time.

-air 7oss
"ome chemotherapy will cause no hair loss, while others will cause partial or total baldness. =air loss does not usually happen straight +.6reeman% /ncology C*C% (oyal *orth Shore ospital% 9444 33

away, it may take a few treatments to occur. It may fall out gradually or in clumps. &our hair may also become dry and brittle during chemotherapy. %s losing hair from your head and body is often very distressing we have the !ook :ood eel 0etter 5rogram at Cansupport, a list of wig shops in "ydney and turbans available from the 5ink !adies in the main =ospital foyer. +<M<M0<+B %>& =%I+ T=%T %!!" -3T $I!! 3"3%!!& :+-$ 0%C; $=<> &-3+ T+<%TM<>T =%" I>I"=<.. Suggestions for caring for your scalp and hair' 3se a mild shampoo. 3se a soft hairbrush. 3se low heat when drying your hair. .on#t dye or perm your hair. 3se sunscreen and a hat.

Fertility&Sexuality
"ome chemotherapy can affect your ability to have children. This may be temporary or it may be permanent. It is important that you discuss fertility issues with your doctor before your treatment. 5regnancy can still occur during chemotherapy. %s chemotherapy can be harmful to growing babies it is important that effective contraception is always used throughout your treatment. or males, if permanent sterility is likely to be a problem, you may consider sperm banking. This means that your sperm will be fro/en for future use. This should be done before your first treatment. In females, chemotherapy may affect your hormone production. &our periods may become irregular or stop completely. 0ecause chemotherapy can affect your hormones you may experience menopause like symptoms 1eg hot flushes, dry skin, vaginal dryness and mood swings2. In some cancers these symptoms can be treated with hormone replacement therapy. =owever drugs will not restore fertility. It is important that you and your partner discuss these issues with your .octor. Chemotherapy should not permanently affect your sexual performance or ability to en4oy sex. &ou and your partner may have temporary problems due to fatigue, anxiety or 4ust because you feel unwell. &ou and your partner +.6reeman% /ncology C*C% (oyal *orth Shore ospital% 9444 39

should try to share your feelings with each other or if needed ask to see a counsellor. +<M<M0<+ it is usually temporary.

Excretion of Chemotherapy
It usually takes your body one8week after your treatment to eliminate all the chemotherapy from your body via your body fluids eg. urine, bowel motions, vomitus, semen and vaginal fluid. Therefore it is important to protect other people, both in hospital and at home. .uring this week it is important thatB &ou flush the toilet once on a full flush with the lid down after you have used it. Carers who need to empty vomit bowls or change wet or soiled beds at home wear protective gloves. %ll soiled linen,clothing is washed in the washing machine and hung outside to dry. If you are sexually active, it is advised that you or your partner use condoms for the recommended period.

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Support Services at *1S.uring your treatment you and your family or carer may need advice and assistance from healthcare workers other than nurses and doctors. These services 1listed below2 can be arranged by referral from your health care team. +ccommodation 1for people out of the "ydney metropolitan area2. 0ook directly or through your social worker. *otary 7odge' 5hone HC JJC@A*HJ )lue Gum 7odge' 5hone HC J)*'E)'H 5averton flats 1haematology patients only2 +m,ulatory Care' oncology,haematology outpatient treatment on level (C Cansupport/ Canya and Canteen' % program to provide support and education for people of all ages with cancer as well as their carers and families 5hone JJC@'C)@. Chaplain' % chaplain is available C) hours a day for spiritual and emotional needs. Interpreter service' % free interpreter service is available by appointment. Community 7iaison 1urse' Community nursing and home oxygen supply 1criteria apply2 7eu$aemia foundation' "upport and education for haematology patients. 4ccupational therapist' To assess your ability to safely perform daily tasks at home, advise on techniques and equipment for performing those tasks. (alliative care' To assist you with symptom control, both in hospital and at home. (atient representative' To assist with unresolved problems concerning your treatment in hospital. (harmacist' %dvise, educate and supply your medications. (hysiotherapist' To assist in prevention of and treat complications related to your illness,mobili/ation. (sychiatry' To help you and your carers, family cope with any anxiety or stress you may be experiencing. *espiratory function la,oratory' !ocated in ward AC. Specialist consulting rooms' !ocated at >orth "hore 5rivate =ospital on level ). Social wor$er' To provide you with emotional support, advise on financial matters and transport and accommodation during treatment. Sydney -ome 1ursing' To provide you and your carer with practical and emotional support at home. .ransport' % voluntary service may be available through your social worker.

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)lue Gum 7odge has a courtesy bus available for transport to +>"=. The timetable is available at 0lue :um !odge. 6rays and Scans #0ltrasound/ C. and M*I%' !ocated on !evel C in main building 1+>"=2 or at >orth "hore 5rivate. >uclear Medicine "cans 1:ated heart pool scan, !ung scan, 0one scan and :allium scan2B !ocated in clinic C, on level * main building or at >orth "hore 5rivate. General Services )eautician' (hone' HC JJC@A*CA -airdresser' 5honeB HC JJC@A*CJ Mo,ile phones' These interfere with computerised equipment. 5lease liaise with the ward staff. (ar$ing' +educed parking fees are available through your social worker or from the 5arking -fficer on level *. .elevision hire' % T? hire service is available for inpatients. 2alua,les' +>"= is >-T able to guarantee the safe keeping of valuable items.

)i,liography
0aquiran .elia and :allagher K, (JJA, Cancer Chemotherapy Handbook, !ippincott, >ew &ork >ew "outh $ales Cancer Council, (JJ', Understanding Chemotherapy, >ew "outh $ales Cancer Council -ncology >ursing "ociety, (JJ@, Cancer Chemotherapy Guidelines and Recommendations for Practice, -ncology >ursing "ociety &asko Koyce, (JJA, Nursing Management of Symptoms ssociated !ith Chemotherapy, Meniscus =ealth Care Communications

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