Introduction
Chemotherapy is a type of treatment for cancer where medicine is used to kill cancer cells. It can be given either as a tablet, or as an injection or infusion directly into a vein.
Cancer
Cancer refers to a number of conditions where the body’s cells grow and reproduce uncontrollably. The rapid growth of cancerous cells is known as a malignant tumour. These cells can spread out of the tumour and into other parts of the body to form new tumours.
How chemotherapy is used
There are four main ways that chemotherapy can be used:
To try to cure cancer completely – this is known as curative chemotherapy
To help make other treatments more effective – for example, chemotherapy can be combined with radiotherapy (where radiation is used to kill cancerous cells), or it can be used before surgery
To relieve symptoms – a cure may not be possible for advanced cancer, but chemotherapy may be used to relieve the symptoms and slow the spread of the condition. This is known as palliative chemotherapy
To reduce the risk of the cancer returning after surgery or radiotherapy.
Side effects
Chemotherapy is a very effective cancer treatment and has helped save millions of lives. However, it does cause side effects.
The medications used in chemotherapy are not very good at telling the difference between fast-growing cancer cells and other types of fast-growing cells. These include blood cells, skin cells, the cells on the scalp and the cells inside the stomach.
This means that most chemotherapy medications have a poisonous effect on the body's cells. Common side effects include:
Feeling tired and weak all the time
Feeling sick
Being sick
Hair loss, although this can sometimes be prevented using a technique called a cold cap
Some people only have minimal side effects. However, for most people, a course of chemotherapy can be very unpleasant and upsetting.
In many cases, having chemotherapy will make you feel worse than the cancer you are being treated for.
Living with and adapting to the side effects of chemotherapy can be challenging. But it's important to realise that most, if not all, side effects will disappear once the treatment is complete.
Some people who are about to start chemotherapy are concerned that the harmful effects of chemotherapy can be passed to other people, particularly people who are vulnerable, such as children or pregnant women. However, there is no risk associated with coming into close contact with someone who is having chemotherapy.
How chemotherapy works
There are over 50 different types of chemotherapy medication which can be used to treat hundreds of different types of cancer.
However, they all work in one of the following two ways:
They stop cells from reproducing, which can be very useful in preventing the spread of cancer.
They essentially "trick" cells into self-destructing.
All human cells have a limited lifespan. They eventually die and are replaced by new cells. Chemotherapy medications make the cancer cells "think" that their lifespan has finished.
Depending on the type of cancer you have, you may be given:
Monotherapy – where only one chemotherapy medication is used
Combination therapy – where a combination of different medications is used
When is chemotherapy given?
Depending on the type and severity of your cancer, chemotherapy will be given at different stages of your treatment. You may receive chemotherapy:
Before having surgery to remove a tumour or radiotherapy to shrink it, so that other treatments can then begin (this is known as neo-adjuvant therapy)
In combination with radiotherapy, which is known as chemoradiation
After having surgery or radiotherapy, which is known as adjuvant therapy
Chemotherapy protocols
You will need to have regular chemotherapy over a set period of time for it to be effective.
Dr. B C Shah will draw up a treatment plan that gives details of how many sessions you will need, how long the course should last, and how much time should pass between each session. It is common for there to be a break after each session to allow your body to recover from the effects of the medication.
This treatment plan is known as a chemotherapy protocol. Chemotherapy protocols vary depending on the type of cancer you have and how advanced it is.
An example of a chemotherapy protocol is:
One day of treatment
Seven days of rest
One day of treatment
21 days of rest
This cycle will then be repeated six times over 18 weeks.
Who can use chemotherapy?
Delaying treatment or, in some cases, not having chemotherapy may be recommended if you:
Are in the first three months of pregnancy – using chemotherapy during this time has a very high risk of causing birth defects
Have low levels of blood cells – chemotherapy can lower your blood cell count more, so it could make you feel very ill and, in some cases, vulnerable to infection. Medication and sometimes a blood transfusion may be required to raise your blood cell count
Have severe kidney or liver disease – most chemotherapy medications are processed by your liver and kidneys, so this could have a very harmful effect if your liver and kidneys are already damaged
Have had recent surgery or a wound – chemotherapy can disrupt the body’s ability to heal wounds, so it's usually recommended that the wound heals before treatment begins
Have an ongoing infection – chemotherapy can make you more vulnerable to the effects of infection, increasing your risks of developing serious complications
As chemotherapy is a potentially life-saving treatment, it is usually recommended for most people with cancer, even if they are in poor health and the treatment is likely to make them feel worse.
How chemotherapy is performed
Dr. B C Shah
Many hospitals use multi-disciplinary teams (MDTs) to provide chemotherapy treatment.
MDTs are teams of specialists that work together. Members of your MDT may include a:
Medical oncologist – a specialist in the non-surgical treatment of cancer using techniques such as radiotherapy and chemotherapy
Pathologist – a specialist in diseased tissue
Haematologist – a blood specialist
Psychologist – who can provide support and advice about the psychological and emotional impact of chemotherapy
Clinical nurse specialist (CNS) – who will offer you support throughout your care, from diagnosis.
As well as having a specialist MDT, you may also be assigned a key worker (this is often the CNS). You will be given their details so that you can get in touch with your team at any point during your treatment. They will also be involved in coordinating your care.
Deciding what treatment is best for you can often be confusing. Dr. B C Shah will recommend what they think is the best treatment option, but the final decision will be yours.
Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask Dr. B C Shah.
For example, you may want to find out:
What the purpose of your chemotherapy is – for example, whether it's being used to cure your cancer, relieve your symptoms or make other treatments more effective
What side effects you're likely to experience and whether anything can be done to prevent or relieve them
How effective the chemotherapy is likely to be at curing your cancer or at least slowing it down
Whether any alternative treatments can be used instead of chemotherapy
Blood tests
Before chemotherapy begins, you will need to have a number of blood tests to assess your health and to make sure you can cope with any side effects.
Blood tests are useful for assessing the health of your liver and kidneys. This is important because chemotherapy medications will pass through your liver and kidneys, where they will be broken down. The medication can harm the liver. Therefore, if you have liver damage, it may not be suitable for you until your liver and kidneys have recovered.
Another important role of blood testing is to assess your blood count. This is a measurement of how many blood cells you have.
There are three types of blood cell:
Red blood cells – which carry oxygen around your body
White blood cells – which help fight infection
Platelets – which help the blood to clot (thicken)
Chemotherapy reduces the number of all three types of blood cells.
If you have a low blood count, treatment may be delayed until your blood count has returned to normal. Alternatively, medication can be used to raise your blood count. In some cases, a blood transfusion may be required.
You will have regular blood tests during your chemotherapy so that your liver, kidneys and blood count can be carefully monitored.
You may also need other tests to check how well the cancer is responding to treatment. The tests you require will depend on the type of cancer you have.
Types of chemotherapy
Chemotherapy is usually given in one of two ways:
as a tablet – which is known as oral chemotherapy
injected directly into a vein – which is known as intravenous chemotherapy
The type of chemotherapy you have will depend on the type of cancer and how advanced it is.
Oral chemotherapy
If you are in good health, you may be able to take your tablets at home. However, you will still need to go to hospital for regular check-ups.
It is very important that you only take your tablets on the days specified in your chemotherapy protocol. If you forget to take a tablet, contact Dr. B C Shah for advice. Also contact Dr. B C Shah if you are sick shortly after taking a tablet.
Intravenous chemotherapy
A number of different devices can be used to give chemotherapy medication into a vein.
The type of device used will often depend on the type of cancer you have and your general health. You may be able to choose which device you have, although this is not always possible.
Intravenous chemotherapy is not like having a vaccine, where you are given one quick injection. Instead, chemotherapy medications are slowly released into a vein over a period of time. The time it takes to give one dose can range from several hours to several days.
Occasionally, some people need a continuous low dose of chemotherapy medication over several weeks or months. If this is the case, you may be given a small portable pump that you can take home with you.
The devices used for intravenous chemotherapy are described below.
Cannula
A cannula is a small tube that is placed into a vein on the back of your hand or lower arm. Chemotherapy medication is slowly injected through the tube into your vein. Once the dose of medication has been delivered, the tube can be removed.
Skin-tunnelled catheter
A skin-tunnelled catheter is a fine tube that is inserted into your chest and connected to one of the veins near your heart. The catheter can be left in place for several weeks or months, so that you do not have to have repeated injections. The catheter can also be used to carry out blood tests.
Peripherally inserted central catheter
A peripherally inserted central catheter (PICC) is similar to a skin-tunnelled catheter except the tube is connected to your arm rather than your chest.
Implanted port
An implanted port is a chamber that can be inserted under your skin and connected to a nearby vein. A special needle is placed into the chamber and connected to a drip or used for blood tests.
Other medication
If you are having chemotherapy, check with Dr. B C Shah before you take any other medication, including over-the-counter (OTC) medicines and herbal remedies. Other medication could react unpredictably with your chemotherapy medication.
Pregnancy
You should avoid becoming pregnant while having chemotherapy. This is because many medications used in chemotherapy can cause birth defects.
You will need to use a barrier method of contraception, such as condoms, while having chemotherapy and for a year after your treatment has finished.
Contact Dr. B C Shah immediately if you think you may have become pregnant while having chemotherapy.
Side effects of chemotherapy
It is difficult to predict exactly what side effects you will experience while having chemotherapy. Different people react to treatment in different ways.
A small number of people have very few or even no side effects.
The common side effects of chemotherapy are listed below, although it is unlikely that you will experience them all.
Dr. B C Shah is there to help you cope with the physical and psychological side effects.
When to get urgent medical advice
While the side effects of chemotherapy can be distressing, most do not pose a serious threat to your health.
However, occasionally some side effects can be very serious. For example, if you have a rapid fall in white blood cells, you may be vulnerable to a serious infection.
People having chemotherapy for cancer that developed inside their blood cells or bone marrow are most at risk of serious infections. This is because this type of cancer will already have caused a reduction in white blood cell numbers.
Symptoms of serious infection include:
a high temperature of 38C (100.4F) or above
shivering
breathing difficulties
chest pain
flu-like symptoms, such as muscle aches and pain
bleeding gums or nose
bleeding from other parts of the body that does not stop after applying pressure for 10 minutes
mouth ulcers that stop you eating or drinking
vomiting that continues despite taking anti-sickness medication
four or more bowel movements a day, or diarrhoea
If you have any of these symptoms, contact Dr. B C Shah immediately.
Fatigue
Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue. You may feel generally tired or you may tire very easily after doing normal, everyday tasks.
While having chemotherapy, it is important to get plenty of rest. Do not carry out tasks or activities that you do not feel up to.
Light exercise, such as walking or yoga, can help boost your energy levels, but be careful not to push your body too hard.
If you are working, you may need to ask your employer to let you work part time until your chemotherapy has finished.
Contact your Dr. B C Shah if you are suddenly significantly more tired than usual and you also feel out of breath. Extreme fatigue and shortness of breath can be a sign of anaemia. This is a condition caused by having a low number of red blood cells.
Nausea and vomiting
Nausea (feeling sick) and vomiting (being sick) are common side effects of chemotherapy. They affect around half of all people being treated.
If you have nausea and vomiting, you will be given medication to help control your symptoms. This type of medication is known as an anti-emetic.
Anti-emetics can be given in a number of different ways, including:
as a tablet or capsule, which can either be swallowed or placed under your tongue to dissolve
as an injection or drip
as a suppository, which is a capsule that you put into your rectum (back passage) so that it can dissolve
through a patch that you place on your skin
Continue to take your anti-emetics even if you do not feel sick because they will help prevent your symptoms from returning.
Side effects of anti-emetics include:
Constipation
Flushing of the skin
Problems sleeping (insomnia)
Indigestion
Headaches
There are several different types of anti-emetics. If the one you are taking doesn't work or if it causes too many troublesome side effects, contact Dr. B C Shah. There may be an alternative anti-emetic that works better for you.
Hair loss
Hair loss is a common side effect of some chemotherapy. It usually begins one to three weeks after the first chemotherapy dose. The hair that grows on the side of your head, near your ears, becomes more brittle and thin. Most people have significant hair loss after one to two months.
The scalp is most commonly affected, although hair loss can occur on other parts of the body. These include the arms, legs and face.
Hair loss can be very traumatic, particularly for women.
If you find hair loss particularly difficult to cope with, talk to Dr. B C Shah. They understand how distressing it can be and will be able to give you support and counselling.
You may decide that you want to wear a wig.
Hair loss due to chemotherapy is almost always temporary, and your hair should begin to grow back soon after your treatment has finished.
Around three-quarters of people no longer need to wear a wig or use a head covering six months after their chemotherapy treatment has finished.
Many people find that their newly grown hair is different than before. For example, it may be a different colour or it may be curlier or straighter than it used to be.
Cold cap
It may be possible to prevent hair loss due to chemotherapy by using a cold cap.
A cold cap looks similar to a bicycle helmet. It is designed to cool your scalp while you receive a dose of chemotherapy. In cooling the scalp, the cold cap reduces the amount of blood flow to the scalp. This reduces the amount of chemotherapy medication that reaches it.
Whether or not you can use a cold cap during treatment will depend on the type of cancer you have.
For example, a cold cap cannot be used if you have:
various types of leukaemia, such as acute lymphoblastic leukaemia, which is cancer of the blood cells and mainly affects children
multiple myeloma, which is a cancer that develops inside the bone marrow
non-Hodgkin's lymphoma, which is a cancer that develops inside the lymphatic system (a series of glands and vessels that help protect the body against infection)
With these types of cancers, there is a good chance that cancerous cells could have spread to your skull. Therefore, it would be too dangerous to cool your skull.
Cold caps work better with certain types of chemotherapy medications, and they may not always prevent hair loss.
Increased risk of infection
Chemotherapy lowers the amount of white blood cells in your body. The main function of white blood cells is to fight infection. If the number of white blood cells is reduced, your immune system will be weakened and you will be more vulnerable to infection.
You may be given a course of antibiotics to reduce your risk of developing an infection. You will also need to take extra precautions to protect yourself against infection. For example, you should:
Have good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly.
Avoid contact with people who have an infection, such as chickenpox or flu.
Wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals.
Take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing.
The regular blood count tests that you will have during chemotherapy mean that your Dr. B C Shah should be able to tell you when you are most vulnerable to infection.
You may be advised to take extra precautions, such as avoiding crowded places and using public transport at busy times.
Anaemia
Chemotherapy will lower the amount of red blood cells. These cells carry oxygen around the body. If your red blood cell count drops too low, your body will be deprived of oxygen and you will develop anaemia.
Symptoms of anaemia include:
tiredness – you will feel much more tired than the general level of fatigue associated with chemotherapy
lack of energy
shortness of breath (dyspnoea)
irregular heartbeat
If you have any of these symptoms, contact your Dr. B C Shah as soon as possible.
You may need to have a blood transfusion to help increase the number of red blood cells. Alternatively, a medication called erythropoietin (EPO) can stimulate the production of red blood cells.
It is important to eat a diet that is high in iron. This is because iron helps red blood cells carry more oxygen. Foods that are high in iron include:
dark-green leafy vegetables, such as spinach
iron-fortified bread
beans
nuts
meat
apricots
prunes
raisins
Bruising and bleeding
Chemotherapy can lower the amount of platelets in your body. Platelets are blood cells that help blood to clot (thicken). This prevents excessive bleeding or bruising.
Most chemotherapy medications do not seriously affect the number of platelets. However, a small number of people experience a significant drop in their platelet count.
Symptoms of a low platelet count include:
easily bruised skin
nose bleeds
bleeding gums
Report any of these symptoms to Dr. B C Shah as you may need a blood transfusion to raise your platelet count.
You may need to take extra precautions to avoid damaging your skin and gums including:
using an electric razor to shave
using a soft toothbrush
taking extra care when using knives or other sharp instruments
wearing a thick pair of gloves when gardening
Oral mucositis
In some cases, chemotherapy can cause pain and inflammation of the surface of the inside of your mouth. This is known as oral mucositis.
The severity of your symptoms usually depends on the strength of your medication. People having high-dose chemotherapy usually have more severe symptoms.
The symptoms of oral mucositis usually begin 7 to 10 days after you start chemotherapy.
If you develop oral mucositis, the inside of your mouth will feel sore, as if you have burnt it by eating very hot food. You will probably develop ulcers on the lining of your mouth and, in some cases, on your tongue or around your lips.
The ulcers can be very painful and make it difficult to eat, drink and talk. They may also bleed and become infected.
The symptoms of oral mucositis should clear up a few weeks after your chemotherapy finishes, although a number of medications are available to relieve the symptoms.
Loss of appetite
Some people who have chemotherapy lose their appetite and do not feel like eating or drinking. If you lose your appetite, it is still important to make an effort to eat healthily and drink plenty of liquids.
You may find eating smaller, more frequent meals better than eating three large meals a day. Try sipping drinks slowly through a straw rather than drinking them straight from a glass.
If you have serious problems eating and drinking due to symptoms such as mouth ulcers, you may need to be admitted to hospital and attached to a feeding tube.
You will probably be given a nasogastric tube. This is a tube that passes down your nose and into your stomach. The tube can be removed once you are able to eat and drink normally.
Skin
Some chemotherapy medications can cause your skin to become dry and sore, particularly on your hands or feet. Your nails may become brittle and flakier than usual and white lines may develop across them.
During chemotherapy and for some time after treatment has finished, your skin may become more sensitive to sunlight. Therefore, it is important to take extra precautions to protect your skin from the sun:
Avoid going out in the sun when it is at its hottest – this is usually between 10am and 2pm, although the sun can also damage skin before and after these times.
Use a sunscreen that blocks both ultraviolet A (UVA) and B (UVB) radiation and has a sun protection factor (SPF) of at least 15.
Dress to protect your skin from the sun – for example, wear a wide-brimmed hat to protect your face and scalp and sunglasses to protect your eyes.
Memory and concentration
Some people who have chemotherapy have problems with their short-term memory, concentration and attention span. You may find that routine tasks take much longer than usual.
Exactly why these symptoms appear is unclear. They may be due to a combination of factors, such as fatigue and anxiety. However, the symptoms usually improve after your treatment has finished.
Sleep problems
Sleep problems are a common side effect of chemotherapy. They are thought to affect around half of all people being treated with chemotherapy.
Sleep problems can include difficulty falling asleep (insomnia), and waking up in the middle of the night and being unable to get back to sleep.
The following advice may help to improve your sleep:
Go to bed only when you are sleepy.
If you cannot sleep, leave the bedroom and only return when you feel sleepy.
Only use your bedroom for sleeping and having sex.
Avoid napping during the day. If this is not possible, try to limit your naps to about half an hour.
Avoid stimulants, such as caffeine, for at least six hours before you plan to go to bed.
If this advice does not work, contact your Dr.B C Shah. You may need additional treatment. A type of talking therapy called cognitive behavioural therapy (CBT) has proved to be effective in treating insomnia associated with chemotherapy.
Sexuality and fertility
Many people find that their interest in sex decreases during chemotherapy. However, this is usually temporary and your interest in sex should gradually return after your treatment has finished.
Some chemotherapy medications can stop women being able to conceive and can prevent men from producing healthy sperm. Loss of fertility is usually temporary, although in some cases a person can become permanently infertile.
If there is a risk that you could become permanently infertile, your Dr. B C Shah will discuss the possibility with you before treatment begins.
A number of options are available. Women can have their eggs frozen to be used later in IVF (in-vitro fertilisation). Men can have a sample of their sperm frozen to be used at a later date for artificial insemination.
Diarrhoea and constipation
You may have diarrhoea or constipation a few days after you begin chemotherapy. Dr. B C Shah can recommend suitable medication to help control the symptoms.
Depression
Living with the effects of chemotherapy can be frustrating, stressful and traumatic. It is natural to feel ongoing anxiety and concern about whether your treatment will be successful.
Stress and anxiety can increase your risk of getting depression. You may be depressed if you have been feeling particularly down for two weeks or more and you no longer take pleasure in the things that you used to enjoy.
Contact Dr. B C Shah if you have psychological and emotional difficulties. They will be able to recommend treatments to help improve the symptoms of stress, anxiety and depression.
Joining a support group for people who are having chemotherapy may also help. Talking to other people in a similar situation can often reduce feelings of isolation and stress.
Refusing or withdrawing treatment
In some circumstances, you may think that the benefits of chemotherapy are not worth the poor quality of life due to the side effects of treatment.
For example, if chemotherapy offered no hope of a cure and could only extend your life by a few months, you may feel that the extra few months are not worth undergoing treatment.
However, if you were looking forward to an event such as the birth of a grandchild or the wedding of a son or daughter, you may want to extend your life whatever the cost to your wellbeing.
There is no right answer or recommendation about when chemotherapy should be refused or withdrawn. Dr. B C Shah can give you advice about the likely benefit of continuing with treatment, but the final decision will be yours.
This is obviously a very sensitive topic that you should discuss fully with Dr. B C Shah, family, friends and loved ones. You always have the right to refuse a particular treatment or to ask for the treatment to be stopped if you do not feel it is benefiting you.
Stopping chemotherapy does not mean that any symptoms you have will go untreated. Dr. B C Shah will still provide support and pain relief. This type of care is known as palliative care.
If it's thought that you do not have long to live, it may be recommended that you are admitted to a hospice. Hospices provide care for people from the point at which their illness is diagnosed as terminal to the end of their life, however long that may be.