This article contains answers to some of the most frequently asked questions (FAQs) by patients undergoing chemotherapy. We encourage you to carefully pursue this information and consult with your healthcare provider if you encounter any doubts. It’s important to acknowledge that the details provided are of a general nature, and individual variations are to be expected in each patient’s journey.
1) What is chemotherapy and how is it administered?
Chemotherapy refers to a treatment involving certain drugs, which can inhibit or kill cancer cells. It can be given in the form of injections or oral medications. The majority of injectable chemotherapy drugs are administered through the intravenous (IV) route – either as bolus injections or as infusions lasting minutes to hours. However, some injectable chemotherapy agents are given through intramuscular (in the muscle), subcutaneous (beneath the skin), or intrathecal (in the spinal fluid) routes. Chemotherapy is usually administered in `cycles’- repetitively every few weeks. Each `cycle’ is given over one or several days. Its duration (time interval between two cycles, counting from the 1st day of the initial cycle) and the number of cycles vary between different tumours and different regimens. The majority of solid tumours (e.g. lung, breast, ovarian, gastrointestinal, and other similar tumours) are treated with 4 to 8 cycles (average 6) of chemotherapy administered every 3 to 4 weeks. Some tumours can be appropriately treated with one of many chemotherapy regimens available. The treatment is usually tailor-made for each patient considering their unique condition and may differ from standard published protocols or scientific information.
2) What is the purpose of chemotherapy treatment?
The aim of giving chemotherapy depends on the stage of the cancer being treated. In early-stage disease, it is given to prevent relapses. Whereas, in an advanced stage, the purpose is to control symptoms, improve the quality of life, and in many instances improve survival. The majority of solid tumours are treated with some combination of surgery, radiation, and chemotherapy. Furthermore, most hematological (blood) cancers are primarily treated with chemotherapy with or without radiation.
3) Which tests are necessary prior to the first cycle of chemotherapy and for subsequent cycles?
Depending on the investigations already performed you may be required to undergo some or all of the following tests before starting the 1st cycle of chemotherapy: Complete Blood Count (CBC), Biochemistry (liver and kidney function tests and tumor markers (all done by taking blood sample)), Radiology (X-ray, CT scan, and ultrasound), Biopsy, etc. Furthermore, you may be called between two cycles (mid-cycle evaluation) for some blood tests to check the effect of the preceding cycle of chemotherapy. In the majority of instances, you will be advised to undergo blood tests (typically CBC, but sometimes other biochemical tests) prior to each cycle of chemotherapy. This is important because blood counts need to recover to normal before the next cycle can be administered. So, depending on your specific case the doctor may evaluate the tumour response after a few cycles of chemotherapy with X-rays, CT scans, or other tests.
4) Is hospital admission required for chemotherapy, and what does ‘Day Care’ entail?
Hospitalization may or may not be required, depending on the type of chemotherapy planned and the general condition of the patient. Many chemotherapy regimens are administered as intravenous infusions lasting several hours over one or more days. They can be safely administered in `Day Care’ where you are admitted for a short duration every day and then discharged. When opting for day care chemotherapy, it is essential to schedule an appointment with the day care staff for each cycle. In such case, you are expected to report to the day care at the appointed time and day. Apart from this, some chemotherapy regimens can be safely administered as intravenous push (bolus) in the injection room.
There is a day care in AIIMS Delhi located on the 5th Floor, Main Building, for private category patients and on the 3rd Floor, Golden Jubilee Block, for the general category.
5) Is it guaranteed that I will be cured if I take chemotherapy as prescribed?
The answer to this question is, unfortunately, no. The nature of cancer is such that there is always some chance of relapse (disease coming back) after apparent initial eradication. The chance of relapse varies from one patient to the other and depends on the type of tumour, its stage, the adequacy of treatment, and many other factors. In advanced stages also, only a subset of patients, not all, will experience a positive response to chemotherapy. It is important to appreciate that statistics apply only to a large group of patients. For an individual, the outcome is unique. Let us understand this with an example, when the doctor tells you that the 5-year cure rate is 80%, what he means is this: If 100 patients are treated today and followed up, at the end of 5 years 80 will be alive and free of their disease. The other 20 will experience recurrence at some point of time in that period. It is often very difficult or impossible to predict which group an individual patient will fall into and also when and if the recurrence of cancer will happen.
6) What is the total cost of chemotherapy in my case?
The cost of chemotherapy is variable and depends on the type of cancer, the specific chemotherapy regimen chosen, and the degree of supportive care that each patient requires. The expense of a full chemotherapy course includes the cost of chemotherapy drugs, supportive medicines, and hospitalization. You must understand that the cost prediction is approximate and unforeseen circumstances may lead to overruns. Please consult your doctor about the total cost of chemotherapy in your case.
It is to be noted that the cost of chemotherapy drugs has no correlation with their efficacy. More expensive drugs are not necessarily more effective and vice versa.
7) How will chemotherapy impact my fertility, and what considerations should be taken regarding contraception?
In general, it is safe for patients to continue sexual relations with their partners during their treatment. However, it is imperative that patients in the reproductive age group practice contraception (preferably barrier method) throughout their treatment. Some chemotherapy drugs can cause temporary or permanent infertility. If this is of concern to you then please discuss this issue with your doctor. If you plan to have children after chemotherapy you are advised to discuss the recommended timing with your doctor.
In women of reproductive age group, menstruation can temporarily or permanently cease after some types of chemotherapy.
8) Is my illness contagious, and is there a risk of transmission through close contact or while interacting with children?
Cancer is not a contagious disease and there is no bar on maintaining normal contact with other persons including children. This disease is not transmitted from one person to the other by close contact including sharing utensils, clothes, food, drinks, and sexual activity.
9) Can I continue with the medications for my longstanding diabetes and hypertension, and is it permissible to take prescriptions from other healthcare providers?
Yes, you should continue the medications for chronic disorders like diabetes and hypertension. However, you are urged to tell your oncologist about all the medications that you are taking. You can also take medicines prescribed by other doctors for emergencies; you should tell them about your cancer treatment when you report to them.
10) Can I incorporate Homeopathic treatment alongside the prescribed medical treatment?
You are advised against simultaneously taking medicines that are prescribed under alternative systems of medicine (Homeopathy, Ayurveda, Unani, etc). If you wish to discontinue prescribed treatment and start another form of treatment, you are at liberty to do so.
11) Can I seek a second opinion from another oncologist?
You are welcome to seek opinions from any number of doctors.
12) Can I continue to smoke and chew tobacco?
You are strongly advised to discontinue tobacco use in any form including smoking. Your relatives and friends are also urged to stop tobacco use in any form since it is the single most preventable cause of cancer-related deaths in the population. Furthermore, if you or anyone known to you wishes to seek help with tobacco cessation you can approach us.
13) What are the recommendations regarding food during my treatment?
The single most important recommendation regarding food and drinks is that they should be clean. It is ideal for you to have well-cooked food, served fresh and warm, during the entire period of your treatment. It is suggested that you avoid very spicy food. There is no bar on the consumption of non-vegetarian dishes that are well-cooked. You may also have fruits, which are carefully washed with clean water. Additionally, it is advisable to avoid fruit juices during chemotherapy, as they have no special nutritive value over the corresponding fruits and they can be a source of infection. Furthermore, it is suggested that you should consume clean water in liberal quantities (unless specifically instructed not to do so) throughout your treatment. You should wash your hands with soap and water before each meal and the person serving food should do the same. This is one of the most important measures to prevent infection during chemotherapy. Unhygienic food and beverages (e.g. fruit juices & coconut water from roadside vendors, raw salad at restaurants, etc) consumed during the period of chemotherapy are an important cause of diarrhea and other infections.
14) I have heard that chemotherapy is a very toxic form of treatment. I am scared to take chemotherapy. What should I do?
Like any other treatment modality, chemotherapy does have side effects which can occasionally be severe. The occurrence and severity of each of the under-mentioned side effects vary from one individual to the other and also on the specific chemotherapy regimen used. It is important to understand that all side effects don’t occur in all patients. In fact, the majority of patients are able to complete their prescribed chemotherapy course without major complications. The purpose of acquainting you with this information is to enable you to anticipate and to some extent prevent complications. We hope this will ensure a better partnership between you and your medical team in your treatment. Therefore please don’t be alarmed after reading the subsequent description of potential side effects and complications of chemotherapy. It should also be noted that all new symptoms that occur during chemotherapy may not be caused by the latter; other factors like the progression of the underlying tumour may be operative.
The final decision to give you chemotherapy takes into account the potential risks and benefits of this treatment. Chemotherapy is suggested only if the benefits outweigh the risks.
15) What are the common side effects of chemotherapy?
The relatively common side effects and toxicities of chemotherapy include, but are not restricted to the following:
Nausea and/or vomiting: They may start immediately after chemotherapy or occur several days later. These effects last for a variable period of time (hours to weeks). Some drugs like cisplatin have a high propensity to cause nausea and vomiting. Medications (called anti-emetics) will be given to patients (oral and/or injectable forms) to decrease the incidents & intensity of nausea and vomiting after chemotherapy.
Sores and ulcers in the mouth and throat: These effects typically start a few days after the start of chemotherapy. It is suggested that patients should maintain good oral hygiene by using a soft toothbrush twice a day. Furthermore, they should also use antiseptic mouthwashes (e.g. Hexidine, Povidone-iodine, etc) 2-3 times a day throughout their chemotherapy. Moreover, to relieve mouth pain (in case of ulcers) they may use Xylocaine viscous (to be liberally applied to mouth before every meal).
Diarrhea: This may develop at any time after the start of chemotherapy and is usually due to one of two reasons. First, the chemotherapy drug may affect the cells lining the intestinal epithelium and cause ulceration. Second, it may be due to unhygienic food (e.g. fruit juices & coconut water from roadside vendors, raw salad at restaurants, etc) consumed during the period of chemotherapy.
Constipation: This is usually a side effect of anti-emetics prescribed with the chemotherapy drugs. However, it may also be due to the chemotherapy drugs themselves or the underlying disease. Patients may take Isapgol husk (Naturolax or Softovac powder) 4-6 teaspoonful with water at bedtime for a few days beginning with each cycle of chemotherapy.
Hair loss: You might have partial or complete hair loss during treatment. There is no proven effective measure to prevent this side-effect. You will regain the hair within 4-6 months of completion of chemotherapy.
Skin Toxicity: Many drugs can cause darkening of the skin, particularly in the light-exposed parts of the body. Some drugs can also cause darkening of the nail beds. These side effects are at least partially reversible after the completion of chemotherapy.
Pain and aches in limbs and other parts of the body: Certain drugs like paclitaxel can cause significant pain in limbs, bones, and other body parts. This usually starts within a few hours after starting the drug and lasts for up to a few days. Painkillers can be prescribed by the doctor to overcome this effect.
Low white blood cell (WBC) counts (leukopenia) with or without infection: This complication usually starts about 6 to 7 days after the start of chemotherapy and lasts for a variable period (usually a few days). This side effect of chemotherapy occurs in a somewhat predictable, dose and regimen-dependent manner. Low WBC counts may or may not be associated with infection. The first sign of infection is usually fever (≥ 100 F) although some patients can develop severe infection without fever. The other common indications of infection are chills, sweating, loose motions, sore throat, cough, burning sensation during urination, redness or swelling in the skin or the genital area, unusual vaginal discharge or swelling, etc. Several measures can help to lower the risk of infections, such as following the instructions regarding diet, staying away from people who have colds, flu, or boils, avoiding crowds, and maintaining distance from children who have been recently immunized. Despite these precautions, some patients will develop infection. In the vast majority of patients, infection can be controlled with either oral or injectable antibiotics if it is diagnosed and treated early. In a very small fraction of patients, it may be fatal. Patients must report to the hospital as early as possible if they develop a fever or other signs of infection after the administration of chemotherapy. Furthermore, the doctor may call you to check your blood counts after the 1st or subsequent cycles of chemotherapy. It is to be noted that the risk of developing low blood counts is not altered by any specific food items.
Low platelet counts: This can develop at a variable time after the administration of chemotherapy (usually in the 2nd week) and last from a few days to several weeks. Platelet count is important because the chance of spontaneous bleeding (from nose, gums, skin, or with vomiting or stools) increases with low platelet count particularly when it falls below 20000/mm3 or when accompanied by fever. The most significant site of bleeding is the brain, which can lead to altered consciousness and other manifestations. It is suggested that patients should not take any medications without asking their doctor, prevent cuts during shaving and/or using scissors, and avoid strenuous physical activity that may lead to injury. Platelet transfusions may be required (as decided by your doctor) in some patients.
Anemia: This refers to low hemoglobin levels in the blood and is a well-documented side effect of many chemotherapy drugs. It is often a cumulative effect i.e. it has a higher propensity to occur after several cycles of chemotherapy. Several other factors may contribute to the development of anemia, such as bleeding, heavy or prolonged menstruation, pre-existing malnutrition, poor food intake, etc. Anemia manifests as malaise, weakness, fatigue, palpitations, shortness of breath, poor concentration, etc. The doctor may decide to give the patient packed RBC transfusions to treat this condition or they may require certain medications.
16) What are the less common side effects of chemotherapy?
The relatively uncommon toxicities that may result due to chemotherapy are as follows:
(Extravasation – another word) of the chemotherapeutic drug can cause pain, swelling, and ulceration at the site of injection. Please contact your doctor IMMEDIATELY if you develop any of these symptoms.
Hypersensitivity and anaphylaxis: This usually manifests as a varying combination of urticaria (a type of skin eruption), shortness of breath, chest tightness, palpitations, sweating, and a sinking feeling within a short time (minutes to hours) after starting chemotherapy. The treatment is immediate cessation of the chemotherapeutic drug and other supportive medications. It is an uncommon but potentially serious complication of chemotherapy and is unpredictable. It can happen due to any drug although some like paclitaxel, rituximab, etc have a higher propensity to cause hypersensitivity. This type of reaction can occur after the first or subsequent cycles of chemotherapy. Furthermore, any prior history of allergy should be reported to the doctor.
Heart (Cardiac) Toxicity: Some chemotherapy drugs like doxorubicin, epirubicin, daunorubicin, idarubicin, mitoxantrone, 5-fluorouracil, and Herceptin can cause cardiac toxicity in the form of arrhythmias (irregular cardiac rhythm) or heart failure. This may happen from minutes to years after the administration of chemotherapy. The occurrence of this complication is low; it is usually related to the cumulative dose of the chemotherapy drug and the existence of pre-existing heart diseases.
Kidney (Renal) Toxicity: Patients undergoing chemotherapy are prone to renal toxicity for a variety of reasons. Certain tumors (lymphomas and leukemias) can lyse rapidly after chemotherapy, leading to clogging of kidneys and failure. Some chemotherapy drugs, such as cisplatin, and antibiotics like amikacin can cause direct injury to the kidneys. With appropriate precautions like adequate hydration, urinary alkalinization, and allopurinol, this complication can be prevented to some extent.
Lung (Respiratory) Toxicity: Patients undergoing chemotherapy are prone to develop upper or lower respiratory tract infections due to impaired immunity. These manifest as cough, fever, chest pain, and shortness of breath. In addition to this, some chemotherapy drugs (most notably bleomycin) can cause direct injury to the lung, presenting as cough, shortness of breath, and infiltrates on chest X-ray. Patients must report any of these symptoms to their doctor at the earliest.
Neurotoxity: Some chemotherapy drugs can cause direct injury to peripheral nerves manifesting as tingling, numbness, weakness of muscles, and occasionally constipation. The most commonly implicated drugs are vincristine, cisplatin, and paclitaxel. These effects are partially reversible after further exposure to the drug is stopped. In addition to this, other drugs like ifosfamide and high-dose cytosine arabinoside can cause central nervous system toxicity presenting as altered consciousness. Some drugs like cisplatin can cause hearing impairment, particularly for high frequencies. This is often related to the cumulative dose of the drug.
Liver (Hepatic) Toxicity: Very occasionally chemotherapy drugs or antibiotics can cause toxicity to the liver, which can present as loss of appetite, jaundice, and/or impairment of liver function tests. More commonly these abnormalities are due to the involvement of the liver by the underlying cancer