What causes side effects?

Cancer cells tend to grow fast, and chemo drugs kill fast-growing cells. But because these drugs travel throughout the body, they can affect normal, healthy cells that are fast-growing, too. Damage to healthy tissue causes side effects. Although side effects are not always as bad as you might expect, many people worry about this part of their cancer treatment.

The normal cells most likely to be damaged by chemo are blood-forming cells in the bone marrow; hair follicles; and cells in the mouth, digestive tract, and reproductive system. Some chemo drugs can damage cells in the heart, kidneys, bladder, lungs, and nervous system. In some cases, medicines can be given with the chemo to protect the body's normal cells.

What are common side effects?

You are not alone if you have questions about side effects. Before chemo starts, most people worry about whether they will have side effects and, if so, what they will be like. The most common side effects of chemo are listed here. They are discussed in more detail toward the end of this section.

• Anemia (low red blood cell count)
• Fatigue (extreme tiredness)
• Hair loss
• Increased chance of bruising, bleeding, and infection
• Nausea and vomiting

Chemo may affect parts of your body in the following ways:

• Intestinal and stomach problems
• Appetite and weight changes
• Sore mouth, gums, and throat
• Nerve and muscle problems
• Dry and/or discolored skin
• Kidney and bladder irritation
• Sexual and fertility issues because of effects on reproductive organs

What should I remember about side effects?

• Every person doesn't get every side effect, and some people get few, if any.

• The severity of side effects varies greatly from person to person. Be sure to talk to your doctor and nurse about which side effects are most likely with your chemo, how long they might last, how bad they might be, and when you should call the doctor's office about them. For more information see the section called "When to call your doctor."

• Your doctor may give you medicines to prevent some side effects before they happen.

• Many people have no long-term problems from chemo. And although side effects can be unpleasant, they must be measured against the need to kill the cancer cells.

How long do side effects last?

Most side effects slowly go away after treatment ends because the healthy cells recover over time. The time it takes to get over some side effects and regain energy varies from person to person and depends on many factors, including your overall health and the drugs you were given.

Many side effects go away fairly quickly, but some may take months or years to completely go away. Sometimes the side effects can last a lifetime, such as when chemo causes long-term damage to the heart, lungs, kidneys, or reproductive organs. Certain types of chemo sometimes cause delayed effects, such as a second cancer that may show up many years later.

Patients often become discouraged about how long their treatment lasts or the side effects they have. If you feel this way, talk to your doctor. You may be able to change your medicine or treatment schedule. If needed, your doctor should be able to suggest ways to reduce any pain and discomfort you have.

Common side effects

Anemia

What is anemia?

When you have too few red blood cells, your body tissues don't get enough oxygen to do their work. This condition is called anemia. You may have these symptoms:

• Tiredness (fatigue)
• Dizziness
• Paleness
• A tendency to feel cold
• Shortness of breath
• Weakness
• Racing heart

Things that may help you with anemia:

Try the suggestions listed in the section below called "Fatigue" if your anemia is making you feel very tired. Let your doctor or nurse know if you have any of the symptoms listed above. Your doctor will check your blood cell count (also called a complete blood count or CBC) often during your treatment. If your red blood cell count falls too low, you may need a blood transfusion. Some people can be treated with a growth factor to boost the number of red blood cells the bone marrow makes.

You can get more information in our document titled Anemia in People with Cancer.

Fatigue

What is fatigue?

Fatigue is one of the most common side effects of cancer treatment. It can range from mild lethargy to feeling completely wiped out. It is different from feeling tired after a long day and does not get better with rest or sleep. Fatigue tends to be the worst at the beginning and at the end of a treatment cycle. Like most other side effects, it usually goes away once chemo is complete.

Things that may help you with fatigue:

• Get plenty of rest and allow time during the day for rest periods.

• Talk with your doctor or nurse about a regular exercise program.

• Eat a well-balanced diet, and drink plenty of liquids.

• Limit your activities. Do only the things that are most important to you.

• Get help when you need it. Ask family, friends, and neighbors to pitch in with activities, such as child care, shopping, housework, or driving. For example, you might ask neighbors to pick up some items for you at the grocery store while doing their own shopping.

• Get up slowly to help prevent dizziness after sitting or lying down.

• Let your doctor know if you are having a hard time sleeping at night.

You can get more information in our document called Fatigue in People with Cancer.

Hair loss

How do I deal with losing my hair?

Hair loss (alopecia) can be devastating. But not all chemo drugs will make you lose your hair. Some people have mild thinning that only they notice. Your doctor will be able to tell you if your medicines are likely to make you lose your hair.

If you do lose your hair, it will almost always grow back after the treatments are over. But it might be a different color or texture.

You can lose your hair on all parts of your body, not just your scalp. Eyelashes and eyebrows, arm and leg hair, underarm hair, and pubic hair all may be affected. It usually doesn't happen right away. More often, hair loss begins after a few treatments. At that point, your hair may fall out slowly or in clumps. Any hair that remains may become dull and dry.

Things that may help you with hair loss:

• Use mild shampoos.

• Use soft-bristle hair brushes.

• Use low heat if you must use a hair dryer.

• Don't use brush rollers to set your hair.

• Don't dye your hair or get a perm.

• Have your hair cut short. A shorter style will make your hair look thicker and fuller. It also will make hair loss easier to deal with if it does happen.

• Use a sunscreen, hat, scarf, or wig to protect your scalp from the sun.

• Use a satin pillowcase.

Sometimes, either during the regrowth of your hair or when you are bald, your scalp may feel extra tender, dry, and itchy. It may help to keep your scalp clean by using a moisturizing shampoo and conditioner. Also use gentle creams or lotions on your scalp as needed. Even a gentle scalp massage may make your scalp feel better.

After chemo, your hair's texture and fullness may change. Hair dyes contain chemicals like peroxide that can damage hair. Although there is no research that supports hair dye doing more damage to hair after chemo, most doctors recommend patients do not use hair dyes until hair returns to normal. This may be as long as 6 months after treatment.

Should I cover my head if I lose my hair?

Some people who lose all or most of their hair choose to wear turbans, scarves, caps, wigs, or hairpieces. Others leave their heads uncovered. Still others switch back and forth, depending on whether they are in public or at home with family and friends. Here are tips to follow if you choose to cover your head with a wig or hairpiece:

• Shop for your wig or hairpiece before you lose a lot of hair so you can match your natural color, texture, and style.

• You may be able to buy a wig or hairpiece at a specialty shop just for cancer patients.

• A sales person may be able to come to your home to help you.

• You can get more tips or even buy a wig or hairpiece through our "tlc" Tender Loving Care^® catalog. Call us for a copy or visit the "tlc"^TM Web site at www.tlcdirect.org.

• If you would prefer to borrow rather than buy a wig or hairpiece, call us or check with the social work department at your treatment center.

If you need a hairpiece because of cancer treatment, it is a tax-deductible expense. It may also be at least partly covered by your health insurance. Be sure to check your policy, and ask your doctor to write a prescription for a "hair prosthesis."

Increased chance of bruising, bleeding, and infection

How will chemo affect my blood cell counts?

The bone marrow produces 3 important parts of your blood:

• Red blood cells, which carry oxygen to cells throughout the body
• White blood cells, which fight infection
• Platelets, which help blood to clot and stop bleeding

Chemo destroys some of the bone marrow cells so fewer blood cells are produced. A drop in the levels of any one of these cells leads to specific side effects.

Your doctor will check your blood cell count by doing a test called a complete blood count or CBC. This will be done often during your treatment.

Bleeding or clotting problems

Chemo can affect the bone marrow's ability to make platelets. These are the blood cells that help stop bleeding by plugging up damaged blood vessels and helping your blood to clot. If you do not have enough platelets, you may bleed or bruise more easily than usual, even from a minor injury. A shortage of platelets is called thrombocytopenia.

Report these signs of thrombocytopenia to your doctor:

• Unexpected bruising
• Small red spots under your skin
• Red or pink urine
• Black or bloody bowel movements
• Any bleeding from your gums or nose
• Bad headaches
• Dizziness
• An increase in weakness
• Pain in joints and muscles

Your doctor will check your platelet count often during your treatment. If it falls too low, you may need a platelet transfusion.

Things that may help you avoid problems if your platelet count is low:

• Don't take any medicine without first checking with your doctor or nurse. This includes aspirin and aspirin-free pain relievers, like acetaminophen (Tylenol^®), ibuprofen, and any other medicines you can buy without a prescription. Some of these medicines can weaken the platelets and make bleeding problems worse.

• Don't drink any alcohol (beer, wine, or liquor) unless your doctor says it's all right.

• Use an extra-soft bristle toothbrush to clean your teeth, and talk to your doctor before using dental floss.

• If you have a runny nose, blow gently into a soft tissue.

• Take care not to cut or nick yourself when using scissors, needles, knives, or tools.

• Be careful not to burn yourself when ironing or cooking. Use a padded glove rather than a potholder when you reach into the oven.

• Avoid contact sports and other activities that might cause an injury.

• Drink plenty of fluids and eat enough fiber to reduce the chances you will get constipated.

• Use an electric shaver instead of a razor.

• When bending over, keep your head above your heart.

Infection

Having a low white blood cell count decreases your body's ability to fight infections. One type of white blood cell, the neutrophil, is especially important in fighting infections. A shortage of neutrophils is called neutropenia.

Infections can begin in almost any part of your body and most often start in your mouth, skin, lungs, urinary tract, and rectum.

If your white blood cell count drops too much, your doctor may hold treatment, give you a lower dose of chemo, or give you a growth factor shot that makes your bone marrow put out more white blood cells.

Things that may help you prevent infections:

• Wash your hands often during the day, especially before you eat and after you use the bathroom.

• Stay away from crowds.

• Stay away from people who have diseases you can catch, such as colds, flu, measles, or chicken pox.

• Do not get any immunization shots (vaccines) without first checking with your oncologist (cancer doctor).

• Stay away from people who have recently had an immunization, such as a vaccine for chicken pox or small pox. Check with your doctor about which vaccines are important and how long you should stay away from people who have had them.

• Clean your rectal area very well but gently after each bowel movement. Ask your doctor or nurse for advice if the area becomes sore or if you have hemorrhoids. Also, check with your doctor before using enemas or suppositories.

• Don't cut, bite, or tear the cuticles of your nails.

• Be careful not to cut or nick yourself when using scissors, needles, or knives.

• Use an electric shaver instead of a razor to prevent breaks or cuts in your skin.

• Use an extra-soft bristle toothbrush that won't hurt your gums and talk to your doctor before using dental floss.

• Don't squeeze or scratch pimples.

• Take a warm (not hot) bath, shower, or sponge bath every day. Pat your skin dry using a light touch. Don't rub.

• Use lotion or oil to soften and heal your skin if it becomes dry and cracked.

• Clean cuts and scrapes right away with warm water and soap. Use an antibiotic ointment and cover with a bandage.

• Wear waterproof gloves when gardening or cleaning up after animals and others, especially small children. Wash your hands afterward, since gloves can get holes that are too small to see.

Even if you are extra careful, your body may not be able to fight infections when your white blood cell count is low. Look out for and check your body regularly for signs and symptoms that you might have an infection. Pay special attention to your eyes, nose, mouth, and genital and rectal areas. The symptoms of infection could be:

• Fever of 100.5°F or greater when your temperature is taken by mouth
• Chills
• Sweating
• Loose stools (This can also be a side effect of chemo.)
• A burning feeling when you urinate
• A bad cough or sore throat
• Unusual vaginal discharge or itching
• Redness, swelling, or tenderness, especially around a wound, sore, pimple, IV site, or central venous catheter
• Abdominal (belly) pain

Report any signs of infection to your doctor right away. If you have a fever, don't use aspirin, acetaminophen (Tylenol), or any other medicine to bring your temperature down without first checking with your doctor.

Nausea and vomiting

What can I do about nausea and vomiting?

Nausea and vomiting are 2 of the most common and most dreaded side effects of chemo. How often you feel these side effects and how bad they are depend on the drugs you are getting and how they affect you.

Nausea and vomiting may start during treatment and last a few hours. Sometimes, but less often, severe nausea and vomiting can last for a few days. Be sure to tell your doctor or nurse if you are very nauseated, if you have been vomiting for more than a day, or if your nausea is so bad that you cannot keep liquids down.

The good news is that nausea and vomiting can almost always be lessened by a change in the way you eat and with drugs that help relieve both symptoms (these drugs are called anti-emetics). Different anti-emetics work for different people. You may need to try more than one before you get relief. Don't give up! Keep working with your doctor and nurse to find the anti-emetics that work best for you.

About half of the people getting chemo feel queasy even before treatment begins. This is called anticipatory nausea, and it is very real. The best way to handle anticipatory nausea is by taking effective anti-emetics to prevent vomiting, and by using relaxation techniques.

Things that may help you with nausea and vomiting:

• Avoid big meals so your stomach won't feel too full. Eat frequent, small meals throughout the day instead of 1, 2, or 3 large meals.

• Drink liquids at least an hour before or after mealtime instead of with your meals.

• Eat and drink slowly.

• Stay away from sweet, fried, or fatty foods.

• Eat foods cold or at room temperature so you won't be bothered by strong smells.

• Chew your food well for better digestion.

• If nausea is a problem in the morning, try eating dry foods, such as cereal, toast, or crackers, before getting up. (Don't try this if your mouth is too dry, or if you have sores in your mouth or throat.)

• Drink cool, clear liquids, such as apple juice, tea, or ginger ale that has lost its fizz.

• Suck on ice cubes, mints, or tart candies. (Don't eat tart candies if you have mouth or throat sores.)

• Try to avoid odors that bother you, such as cooking smells, smoke, or perfume.

• Rest in a chair after eating, but don't lie flat for at least 2 hours after you've finished your meal.

• Wear loose-fitting clothes.

• Breathe deeply and slowly when you feel nauseated.

• Distract yourself by talking with friends or family members, listening to music, or watching a movie or TV show.

• Use relaxation techniques.

You can get more tips and details in the document called Nausea and Vomiting.

Other chemo side effects and tips to manage them

Appetite changes

There may be days when you just can't eat because of things like nausea or mouth and throat problems. You also can lose your appetite if you feel depressed or tired.

When you have a poor appetite, try these tips:

• Eat small meals or snacks whenever you want. You don't have to eat 3 regular meals each day.

• Vary your diet, and try new foods and recipes.

• Take a walk before meals whenever you can. This may make you feel hungrier.

• Change your mealtime routine. For example, eat by candlelight or in a different place.

• Eat with friends or family members. When eating alone, listen to the radio or watch TV.

• If you live alone, you might want to arrange for Meals on Wheels or a program like this to bring food to you. Ask your doctor, nurse, or local American Cancer Society office about services in your area.

For more information, please see our booklet called Nutrition for the Person with Cancer During Treatment: A Guide for Patients and Families or Nutrition for Children with Cancer.

Constipation

Some people become constipated from chemo. Others may become constipated because they are less active, eat less than usual, have diet changes, or because they are taking certain pain medicines. Tell your doctor if you have not had a bowel movement in 2 or more days. You may need to take a laxative or stool softener, but don't use these unless you have checked with your doctor, especially if your white blood cell count or platelet count is low.

Things that may help you deal with constipation:

• Drink plenty of fluids to help keep your stool soft. Warm and hot fluids work especially well.

• Eat a lot of high-fiber foods. High-fiber foods include bran, whole-wheat breads and cereals, raw or cooked vegetables, fresh and dried fruit, nuts, and popcorn.

• Get some exercise. Just getting out for a walk can help, as can a planned exercise program. Be sure to check with your doctor before increasing your physical activity.

Diarrhea

When chemo affects the cells lining the intestine, it can cause diarrhea. Diarrhea is most often defined as 2 or more loose stools in 4 hours. If you have diarrhea that lasts for more than 24 hours, or if you have pain and cramping along with it, call your doctor. In severe cases, the doctor may have you take an anti-diarrheal medicine, but don't take any over-the-counter anti-diarrheal medicines without asking your doctor first.

Things that may help you control diarrhea:

• Eat smaller amounts of food, but eat more often.

• Avoid coffee, tea, alcohol, and sweets.

• Avoid high-fiber foods, which can lead to diarrhea and cramping. High-fiber foods include whole-grain breads and cereals, raw vegetables, beans, nuts, seeds, popcorn, and fresh and dried fruit.

• Eat low-fiber foods, such as white bread, white rice or noodles, creamed cereals, ripe bananas, canned or cooked fruit without skins, cottage cheese, yogurt, eggs, mashed or baked potatoes without the skin, pureed vegetables, chicken or turkey without the skin, and fish.

• Stay away from fried, greasy, or spicy foods.

• Avoid milk and milk products if they make your diarrhea worse.

• Eat more potassium-rich foods, such as bananas, oranges, potatoes, and peach and apricot nectars, unless your doctor has told you otherwise.

• Drink plenty of fluids to replace those you have lost through diarrhea. Mild, clear liquids, such as apple juice, water, weak tea, clear broth, or ginger ale are best. Make sure they are at room temperature and drink them slowly. Let carbonated drinks lose their fizz before you drink them.

If your diarrhea is severe (meaning that you have had 7 or 8 loose movements in 24 hours), tell your doctor right away. Ask if you should try a clear-liquid diet to give your bowels time to rest.

As you feel better, slowly add the low-fiber foods. A clear-liquid diet doesn't have all the nutrients you need, so don't follow it for more than 3 or 4 days. If your diarrhea doesn't get better, you may need to get IV fluids to replace the water and nutrients you have lost.

Mouth, gum, and throat problems

Good mouth care is important during cancer treatment. Chemo can cause sores in the mouth and throat. It can make these areas dry and irritated or cause them to bleed. Mouth sores are not only painful, but they can also become infected by the many germs that normally live in your mouth. Infections can be hard to fight during chemo and can lead to serious problems. It's important to take every possible step to prevent them.

Ways to keep your mouth, gums, and throat healthy:

• Have your teeth cleaned and take care of any cavities, abscesses, gum disease, or poorly fitting dentures before you start chemo.

• Ask your dentist to show you the best ways to brush and floss your teeth during chemo.

• Ask about a daily fluoride rinse or gel to help prevent decay because chemo can make you more likely to get cavities.

• Brush your teeth and gums after every meal. Use an extra-soft bristle toothbrush and a gentle touch; brushing too hard can damage soft mouth tissues.

• Ask your dentist to suggest a special type of toothbrush, floss or dental ribbon, and toothpaste if your gums are very sensitive.

• Rinse your toothbrush well after each use, and store it in a dry place.

• Avoid commercial mouthwashes. They often contain irritants such as alcohol. Instead, ask your doctor or nurse about a mild mouthwash or a mouthwash with antibiotics to help prevent mouth infections.

If you develop sores in your mouth (this is called stomatitis), tell your doctor or nurse right away because you may need treatment.

If the sores are painful or keep you from eating, try these tips:

• Ask your doctor if there is anything you can put right on the sores to treat them and if there is medicine you can take to ease the pain.

• Eat foods cold or at room temperature. Hot and warm foods can irritate a tender mouth and throat.

• Choose soft, soothing foods, such as ice cream, milk shakes, baby food, soft fruits (like bananas and applesauce), mashed potatoes, cooked cereals, soft-boiled or scrambled eggs, cottage cheese, macaroni and cheese, custards, puddings, and gelatin. You also can puree cooked foods in the blender to make them smoother and easier to eat.

• Avoid irritating, acidic foods, such as tomatoes, citrus fruit, and citrus fruit juice (orange, grapefruit, and lemon); spicy or salty foods; and rough, coarse, or dry foods like raw vegetables, pretzels, granola, and toast.

If your mouth is dry and it bothers you or makes it hard for you to eat, try these tips:

• Ask your doctor if you should use an artificial saliva product to moisten your mouth.

• Drink plenty of liquids.

• Suck on ice chips, Popsicles, or sugarless hard candy.

• Chew sugarless gum.

• Moisten dry foods with butter, margarine, gravy, sauces, or broth.

• Dunk crisp, dry foods in mild liquids.

• Eat soft and pureed foods.

• Use lip balm if your lips become dry.

Nerve and muscle problems

Certain chemo drugs can cause peripheral neuropathy, a nerve problem that causes tingling, pins and needles, burning sensations, weakness, and/or numbness in your hands and feet.

You may feel any of these nerve-related symptoms:

• Loss of balance
• Clumsiness
• Trouble picking up objects and buttoning clothing
• Problems walking
• Jaw pain
• Hearing loss
• Vision changes
• Stomach pain
• Constipation

Along with affecting the nerves, certain chemo drugs can affect the muscles and make them weak, tired, or sore.

Nerve and muscle effects are frustrating, yet in most cases they are not serious if caught early. They are usually short term and will get better after treatment is done. Still, it is important to tell your doctor about any nerve or muscle symptoms right away. They can get worse and become quite painful if left untreated. Your doctor might want to stop the chemo for awhile or offer you treatment to ease these symptoms.

Caution and common sense can help you deal with nerve and muscle problems.

Follow these tips:

• If your fingers become numb, for example, be very careful when handling objects that are sharp, hot, or otherwise dangerous.

• If your sense of balance is affected, move carefully, use handrails on stairs, and use a bath mat in the tub or shower.

For more information see our document called Peripheral Neuropathy Caused by Chemotherapy.

Skin and nail changes

You may have minor skin problems during treatment, including color changes, redness, itching, peeling, dryness, rashes, and acne.

You can take care of most of these problems yourself using these tips:

• If you develop acne, try to keep your face clean and dry.

• For itching, try cornstarch.

• To help avoid dryness, take quick, warm showers rather than long, hot baths.

• Apply creams or lotions after bathing, while your skin is still moist.

• Do not use perfume, cologne, or aftershave lotion. These products often contain alcohol, which can make your skin dry.

When given through an IV, certain chemo drugs, may darken your skin along the vein. This discoloration will usually fade over time after treatment ends.

Most skin problems are not serious, but a few need to be taken care of right away. For example, certain drugs given through an IV can cause serious, long-term tissue damage if they leak out of the vein. Tell your doctor or nurse right away if you notice swelling or feel any burning or pain near your IV site when you are getting IV drugs. These symptoms don't always mean there's a problem, but they should always be checked out right away.

Let your doctor or nurse know right away if you develop sudden or severe itching, if your skin breaks out in a rash or hives, or if you start wheezing or have any other trouble breathing. These symptoms may mean you are having an allergic reaction that needs attention right away.

Some chemo drugs may make your skin more sensitive to the sun. Check with your doctor or nurse about using sunscreen. You may need to completely avoid direct sunlight. Wear long-sleeved cotton shirts, hats, and pants to block the sun.

Your nails may become darkened, brittle, or cracked, or they may develop vertical lines or bands. Protect your nails by wearing gloves when washing dishes, gardening, or doing other work around the house. Some over-the-counter products might strengthen your nails, but these products may also cause irritation.

Get advice from your doctor if any skin and nail problems don't respond to your efforts. Be sure to let your doctor know if you have redness, pain, or changes around your cuticles or any other skin problems that you are worried about.

Urine changes and bladder and kidney problems

Some chemo drugs can irritate your bladder or cause short- or long-term kidney damage. They may also cause your urine to change color (orange, red, or yellow) or take on a strong or medicine-like odor. For a short time, the color and odor of semen may be changed, too.

Ask your doctor if your chemo may have these effects. And let your doctor know if you have any symptoms that might be a sign of a problem. Watch for these signs and symptoms:

• Pain or burning when you urinate
• Urinating a lot
• A feeling that you must urinate right away
• Reddish or bloody urine (Some chemo drugs will change the color of your urine. Tell your doctor or nurse if this happens.)
• Fever
• Chills

Drink plenty of fluids to ensure good urine flow and help prevent problems. Water, juice, coffee, tea, soup, soft drinks, broth, ice cream, Popsicles, and gelatin count as fluids.

Weight gain

Some people, usually women, put on weight during chemo. We are not sure why this happens, but it may have to do with intense food cravings that develop despite the nausea. The average weight gain for women is about 7 pounds.

Whether you gain weight or not, good nutrition is very important during treatment. People who eat well cope with side effects better and are better able to fight infection. Their bodies can also rebuild healthy tissues faster.

Eating well during chemo means choosing a balanced diet that contains all the nutrients your body needs. You should include foods from each of the following food groups: fruits and vegetables; poultry, fish, and meat; cereals and breads; and dairy products. You also should take in enough calories to keep your weight up and, most importantly, enough protein to build and repair skin, hair, muscles, and organs.

You also may need to drink extra fluid to protect your bladder and kidneys during your treatment.

Go back to Understanding Chemotherapy: A Guide for Patients and Families.

Last Medical Review: 11/02/2009
Last Revised: 11/02/2009