The Next Fight

Nausea and vomiting made the already scary experience of chemotherapy even rougher for Lynn Lindstrom. But when the Inver Grove Heights woman started taking Emend capsules before her chemotherapy sessions for breast cancer, her symptoms suddenly subsided.

“They were phenomenal,” says Lindstrom, an elementary education teaching assistant who was diagnosed in June 2005. “I’m glad there are people out there researching this stuff, because I got a lot of relief.”

Surgery, chemotherapy, radiation, and adjuvant therapy can mean a long, healthy life for women with breast cancer, but they also carry a host of potentially incapacitating side effects. Fortunately, medicine has evolved to the point that it is able to lessen some—but not all—of these adverse effects.

Tackling the Side Effects of Chemotherapy
Of all the breast cancer therapies, chemotherapy presents the biggest burden to patients. Nausea and vomiting, hair loss, fatigue, cracking of the fingernails and toenails, and cognitive difficulties are common, though the occurrence and severity of these symptoms depend on the drug and dosage used, as well as on the individual patient. There’s good news, though.

“The toxicity of chemo-therapy has become more manageable and the duration of treatment has become shorter (eight to sixteen weeks rather than six to twelve months),” says Gail Bender, MD, a medical oncologist at Ridgeview Medical Center in Waconia. “Patients should not be deterred from seeking chemotherapy because of the side effects; there are also side effects to letting the cancer progress.”

Nausea and vomiting may occur as a response to chemotherapy through two mechanisms. The first is the injury of stomach cells that start the process of nausea and vomiting. The second is  activation of the area of the brain responsible for producing these symptoms. Chemotherapy drugs typically cause such reactions within a few hours of treatment, and some also cause another period of these symptoms a day later.

Some anti-nausea drugs, such as Emend, are taken before chemotherapy to prevent nausea and vomiting, and others, such as the serotonin antagonist Granisetron, may be administered during the session, says Tom Flynn, MD, a medical oncologist and president of MN Oncology Hematology in Minneapolis. “Certainly, compared to ten or fifteen years ago, we have much better drugs,” he says. “There are better drugs—and more choices—to treat nausea.”

It’s also important to remember that some drugs work better than others in some people. “Every patient is different,” Bender says. “Some people need stronger drugs, and some people need three drugs.”

Chemotherapy can wipe out a woman and can also lead to a risk of infection if it causes a patient’s white blood cell count to dip. To combat fatigue, rest, regular exercise, and adequate sleep are essential.

“We are all overbusy these days,” Bender says. “Chemotherapy patients need to realize that there is going to be a period of time when they just won’t be able to do as much.”

If fatigue is due to anemia, Flynn says, Erythropoietin can be used to boost hemoglobin and replenish energy. Likewise, if a woman’s white blood cell count drops precipitously, drugs called colony-stimulating factors are available to produce a more rapid recovery of white blood cells.

Chemotherapy also tends to harm the nails, one more reminder of the toxic effects of the treatment. “The chemotherapy can cause the nails to become dry and crack,” says Amy Spomer, MD, chair of oncology services at Park Nicollet Clinic in St. Louis Park.

Doctors have found that wrapping a patient’s hands in cold packs or plunging them into an ice bath during chemotherapy prevents the drugs from getting to the nails by restricting the blood flow to that area.

Unfortunately, despite many advances, doctors are currently not able to ameliorate the memory loss, concentration problems, and other cognitive difficulties collectively called “chemobrain” that can arise from chemotherapy treatment. 

A limited number of patients have had early success avoiding chemotherapy-induced hair loss through the use of so-called “cold caps” (see this month's article, “Treating the Woman Inside”), but they do not work in everyone and with all drug regimens, and some physicians are reluctant to use them for fear that the caps will prevent the chemotherapy from reaching cancer cells in the brain.

Singling out the Sentinel Lymph Node
Surgeons used to remove a large number of lymph nodes under the arm nearest the cancerous breast to assess the risk of the cancer spreading throughout the body. However, that often led to an uncomfortable swelling of the arm and hand called lymphedema, particularly if the surgery was followed by radiation therapy.

Swelling happens as lymphatic fluid builds up in the hand and arm because lymph nodes in the armpit are no longer there to assist in its movement back into circulation. Lymphedema, which typically appears within a few months of surgery, also carries a higher risk of local infection because the mechanisms to clear infection in the arm and hand are not working well.

Surgeons now usually remove only the node called the “sentinel node,” or the one most likely to have cancer cells. If the sentinel node is clean, they stop there, preventing most cases of lymphedema, says Khalid Mahmud, MD, president of Innovative Directions in Health in Edina.

Mahmud says the risk of lymphedema can also be minimized by avoiding the use of radiation in early-stage cancers since the radiation could damage the lymph nodes and result in a backlog of lymphatic fluid. “It’s not definitely proven that radiation would be beneficial in those cases,” says Mahmud, a former oncologist who currently does not treat breast cancer but specializes in the prevention of breast cancer recurrences through the use of non-drug therapies.

If lymphedema does occur, lymphatic massage, physical therapy, and decompression treatments such as wrapping the arm in bandages or using mechanical pumps can help improve blood flow in the arm, relieving the swelling. Most hospitals have a lymphedema clinic that offers all of these services.

Radiation and Adjuvant Therapy Side Effects
While it is killing cancer cells, radiation is also damaging normal skin cells, which can lead to skin sensitivity and peeling and blistering of the skin that is much like that from a bad sunburn. “The skin damage caused by radiation is usually much better within several weeks of completion of radiation, but most patients will have some residual discoloration,” says Mark Palmer, MD, radiation oncologist at United Hospital in St. Paul, who notes that a high-quality moisturizer, such as Aquaphor, can help soothe the skin.

Another major complaint from people who have undergone radiation after chemotherapy is fatigue. Unless it is due to anemia, for which there are medications, rest, sleep, and mild to moderate regular exercise (such as walking) are the only available antidotes. The fatigue usually subsides within several months of completion of the therapy, although this can vary from patient to patient.

Drugs that are given as adjuvant, or preventive, therapy are meant to interfere with hormone receptors associated with breast cancer and thus may cause symptoms associated with menopause, such as hot flashes, vaginal dryness, thinning of scalp hair, osteoporosis, reduced sex drive, and cognitive problems. “[The patient’s] hormones are down to nothing, and their quality of life diminishes as a result,” says Mahmud, who prescribes bioidentical estrogen creams for women who have gone five years without a recurrence of breast cancer.

When the symptoms of adjuvant therapy become too difficult for the patient, Spomer switches drugs or prescribes antidepressants. “It can certainly lessen the severity of symptoms,” she says.

Flynn says progesterone-like medications and some anticonvulsants can be helpful to combat hot flash symptoms. “The symptoms do tend to get better over time, but for some women, they can be very bothersome,” he says.

Be Kind to Yourself
Lindstrom, who will be forty-six next month and is taking Arimidex to prevent a recurrence of her cancer, says the side effects themselves weren’t as difficult as admitting that she couldn’t do everything herself anymore. “The hardest thing for me was to say ‘I need help,’” she says.

The last of her thirty-three radiation treatments took place in February, but the fatigue still lingers, and she is trying to learn to live with the cognitive effects of her chemotherapy. “I have to write everything down—even today,” Lindstrom says. “It’s very frustrating because you go into a room for something and then you think ‘Why am I here?”

But antidepressants have helped alleviate the hot flashes and night sweats, and she tries to view her experiences in a positive light. Above all, though, she says she has learned something very important—something that’s not just applicable to breast cancer survivors: “Be kind to yourself.”