Dealing with the Side Effects of Treatment Now and Later
One other acute side effect is bone marrow suppression. When we give chemotherapy, these are cytotoxic drugs, and they go and kill cancer cells, but they like to also kill fast dividing cells in the body. And the bone marrow is a very active organ, because it produces red cells, white cells, and platelets. As you know, the platelets are the cells which help with blood clot formation and prevent bleeding. The white cells fight infection and the red cells obviously carry oxygen and if red cells go down, we have anemia.
Because these cells are fast dividing, chemotherapy suppresses them 7to 14 days after chemotherapy and we see a dip in these counts. So we have some of the drugs causing significant neutropenia Some of the drugs don’t and we pretty much know which drugs are causing more neutropenia. I think it is important to know that if you take this drug, not to be around infected people and maybe to wear a mask or do a lot of hand washing. We also tell our patients, which is a very important management point, that when the bone marrow suppressive drugs are taken and our patients develop a fever and temperatures and signs of infection, they really have to come to the doctor because we need to check the counts and see if there’s an active infection going on, because having low white counts is something--but having low counts and being infected is another issue, which is very important. Then we might even have to admit our patients to give some antibiotics.
But if it’s just low counts and nothing else, no infection, we don’t admit, we just follow and then maybe decide whether next time we should either decrease the dose, or give some growth factor support. For example, for those who have received (inaudible) GCSF or the trade name Nupagen, Neulasta the daily shots we give sometimes to kind of boost the bone marrow to produce more cells faster, so that there is no time to develop infections. But it all depends again on the degree of the bone marrow suppression, the risk of infection and the type of the chemo, so that needs to be discussed again with your healthcare provider and with your doctor.
In terms of the rest of the bone marrow, besides developing decreased white cells, and the risk of infection, some of the drugs can cause anemia. I think with our breast cancer drugs that rate is very low. We don’t do as much transfusion as other diseases, because our drugs really don’t cause a lot of anemia. It goes down a little bit, causes fatigue and if that happens, and if the fatigue is significant, then we can give growth factor support or a blood transfusion.
And then the platelets again are the cells which help with blood clot formation and prevent bleeding. If they are too low there is a risk of bleeding. That again, I don’t remember that I ever was in the last ten to 15 years ever transfused any patient, any of my patients with platelets, because our drugs simply don’t affect the platelets that much. And if it is, it’s really a little bit and not a lot. So we are not worried a lot about platelets and bleeding with our treatments. And if it happens, there must be maybe another reason going on in the bone marrow which requires then further investigation.
I want to come back to the fatigue a little bit with chemotherapy. Everybody, somehow, to some type of degree experiences fatigue and that can be from, range from grade one to two, three, up to grade four. And I cannot say it’s related to a certain drug because sometimes we see that one patient has just a little bit fatigue, tiredness with the drugs, and another patient has extreme fatigue with the same drug. So most probably they are factors in the body which contributes to that. And of course, we also have to make sure that your doctor makes sure that there are no other reasons, so hypothyroidism, like thyroid dysfunction that can cause fatigue and there might be some other reasons, and maybe it’s not only the chemotherapy.
As I mentioned, anemia can cause fatigue too, so if the red cells really go down, then we might have to be proactive and give some blood transfusion to improve and increase quality of life.
Some drugs have some certain specific side effects. Some drugs cause soreness of the mouth and throat and it can, that can be from manageable to a grade of non-manageable where a patient cannot even eat and drink. Again with breast cancer drugs, it happens rarely, but it might happen and we have drugs available which is sometimes rinsed and swallowed actually, if there’s also some soreness in the throat, which has a pain killer in it, local anesthetic, but also an antiseptic which prevents some infections, because you want to make sure that these sores don’t get infected. Otherwise you will need to get IV antibiotic treatment.
We have a number of our patients complaining of nail changes, hand and foot. And again certain drugs are known to cause it more than others. As long as the, there’s hygiene and it does not look infected, I think its okay, you just have to be careful and if there is a purulent, bad smelling, darkish green fluid coming out and it looks infected, sometimes the podiatrist may have to pull the nail. But that’s very rare, usually its only discoloration, the color changes, it looks ugly, but then after chemotherapy it goes away and improves. But a number of patients initially get scared of this, but then it gets better.
Some drugs can also cause lacrimation like tearing in the eyes, Taxotere or docetaxel can cause that. Recognizing it early is important. We send our patients to ophthalmology before we start docetaxel because if there is a little narrowing in the tearing canal, then they can put a little silicon tube in it so that the narrowing does not get worse with the treatment. Otherwise, there will be a lot of lacrimation from the eye. But that’s also fixable and after chemotherapy they actually can take that silicon tube out and then there are no problems any more. A drug called Capecitabine or the other name Xeloda can cause what we call hand/foot syndrome that is soreness, redness in the hands and palms and fingers. It is really drug and dose related, so it doesn’t happen right away, it happens with several cycles and with higher doses. And there is no magical drug to prevent that really. When that happens we stop the treatment for a week or two weeks until it regresses and then start back on a lower does. Very rarely it can never start, but most of the time we are really able to start at a lower dose and continue with the drug, if that drug is working because we don’t want to stop something that is working. We want to kind of handle the side effects and go around it.
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