Chemotherapy

*Chemotherapy facts by Benjamin Wedro, MD, FACEP, FAAEM

• Chemotherapy is one option available to treat cancer patients.
• The types of medication used and how they are administered depends upon the patient's situation, the type of cancer, and the goal of cancer therapy.
• Chemotherapy options are individualized for each patient. Treatment decisions are usually a collaboration between the patient, family, and cancer doctor.
• There are different goals for chemotherapy. The treatment may be meant to cure the cancer, control its growth and spread, or provide comfort to the patient.
• Chemotherapy affects people in different ways. The most common side effect is fatigue but other more serious complications may occur, depending upon the type of chemotherapy treatment.
• The battle to treat cancer is ongoing. There are many new chemotherapeutic drugs and treatment protocols being developed. Clinical trials may be an option for some patients with cancer, but there is no guarantee that a new drug or treatment will work or is better than standard available treatment.

Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to destroy cancer cells.

Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly. It can also harm healthy cells that divide quickly, such as those that line your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side effects. Often, side effects get better or go away after chemotherapy is over.

Depending on your type of cancer and how advanced it is, chemotherapy can:

• Cure cancer - when chemotherapy destroys cancer cells to the point that your doctor can no longer detect them in your body and they will not grow back.
• Control cancer - when chemotherapy keeps cancer from spreading, slows its growth, or destroys cancer cells that have spread to other parts of your body.
• Ease cancer symptoms (also called palliative care) - when chemotherapy shrinks tumors that are causing pain or pressure.

Sometimes, chemotherapy is used as the only cancer treatment. More often, you will get chemotherapy along with surgery, radiation therapy, or biological therapy. Chemotherapy can:

• Make a tumor smaller before surgery or radiation therapy. This is called neo-adjuvant chemotherapy.
• Destroy cancer cells that may remain after surgery or radiation therapy. This is called adjuvant chemotherapy.
• Help radiation therapy and biological therapy work better.
• Destroy cancer cells that have come back (recurrent cancer) or spread to other parts of your body (metastatic cancer).

This choice depends on:

• The type of cancer you have. Some types of chemotherapy drugs are used for many types of cancer. Other drugs are used for just one or two types of cancer.
• Whether you have had chemotherapy before
• Whether you have other health problems, such as diabetes, heart disease, or problems with the liver or kidneys.

You may receive chemotherapy during a hospital stay, at home, or in a doctor's office, clinic, or outpatient unit in a hospital (which means you do not have to stay overnight). No matter where you go for chemotherapy, your doctor and nurse will watch for side effects and make any needed drug changes.

Treatment schedules for chemotherapy vary widely. How often and how long you get chemotherapy depends on:

• Your type of cancer and how advanced it is
• The goals of treatment (whether chemotherapy is used to cure your cancer, control its growth, or ease the symptoms)
• The type of chemotherapy
• How your body reacts to chemotherapy

You may receive chemotherapy in cycles. A cycle is a period of chemotherapy treatment followed by a period of rest. For instance, you might receive 1 week of chemotherapy followed by 3 weeks of rest. These 4 weeks make up one cycle. The rest period gives your body a chance to build new healthy cells.

It is not good to skip a chemotherapy treatment. Sometimes your doctor or nurse may change your chemotherapy schedule. This can be due to side effects you are having. If this happens, your doctor or nurse will explain what to do and when to start treatment again.

Chemotherapy may be given in many ways.

• Injection. The chemotherapy is given by a shot in a muscle in your arm, thigh, or hip or right under the skin in the fatty part of your arm, leg, or belly.
• Intra-arterial (IA). The chemotherapy goes directly into the artery that is feeding the cancer.
• Intraperitoneal (IP). The chemotherapy goes directly into the peritoneal cavity (the area that contains organs such as your intestines, stomach, liver, and ovaries).
• Intravenous (IV). The chemotherapy goes directly into a vein.
• Topically. The chemotherapy comes in a cream that you rub onto your skin.
• Orally. The chemotherapy comes in pills, capsules, or liquids that you swallow.

Things to know about getting chemotherapy through an IV

Chemotherapy is often given through a thin needle that is placed in a vein on your hand or lower arm. Your nurse will put the needle in at the start of each treatment and remove it when treatment is over. Let your doctor or nurse know right away if you feel pain or burning while you are getting IV chemotherapy.

IV chemotherapy is often given through catheters or ports, sometimes with the help of a pump.

• Catheters. A catheter is a soft, thin tube. A surgeon places one end of the catheter in a large vein, often in your chest area. The other end of the catheter stays outside your body. Most catheters stay in place until all your chemotherapy treatments are done. Catheters can also be used for drugs other than chemotherapy and to draw blood. Be sure to watch for signs of infection around your catheter.
• Ports. A port is a small, round disc made of plastic or metal that is placed under your skin. A catheter connects the port to a large vein, most often in your chest. Your nurse can insert a needle into your port to give you chemotherapy or draw blood. This needle can be left in place for chemotherapy treatments that are given for more than 1 day. Be sure to watch for signs of infection around your port.
• Pumps. Pumps are often attached to catheters or ports. They control how much and how fast chemotherapy goes into a catheter or port. Pumps can be internal or external. External pumps remain outside your body. Most people can carry these pumps with them. Internal pumps are placed under your skin during surgery.

Chemotherapy affects people in different ways. How you feel depends on how healthy you are before treatment, your type of cancer, how advanced it is, the kind of chemotherapy you are getting, and the dose. Doctors and nurses cannot know for certain how you will feel during chemotherapy.

Some people do not feel well right after chemotherapy. The most common side effect is fatigue, feeling exhausted and worn out. You can prepare for fatigue by:

• Asking someone to drive you to and from chemotherapy
• Planning time to rest on the day of and day after chemotherapy
• Getting help with meals and childcare the day of and at least 1 day after chemotherapy

There are many ways you can help manage chemotherapy side effects.

Many people can work during chemotherapy, as long as they match their schedule to how they feel. Whether or not you can work may depend on what kind of work you do. If your job allows, you may want to see if you can work part-time or work from home on days you do not feel well.

Many employers are required by law to change your work schedule to meet your needs during cancer treatment. Talk with your employer about ways to adjust your work during chemotherapy. You can learn more about these laws by talking with a social worker.

Sometimes your doctor may advise you not to work from a period of time, such as when your immune system is low during chemotherapy.

This depends on the type of chemotherapy you get and the other types of drugs you plan to take. Take only drugs that are approved by your doctor or nurse. Tell your doctor or nurse about all the over-the-counter and prescription drugs you take, including laxatives, allergy medicines, cold medicines, pain relievers, aspirin, and ibuprofen.

One way to let your doctor or nurse know about these drugs is by bringing in all your pill bottles. Your doctor or nurse needs to know:

• The name of each drug
• The reason you take it
• How much you take
• How often you take it

Talk to your doctor or nurse before you take any over-the-counter or prescription drugs, vitamins, minerals, dietary supplements, or herbs.

Can I take vitamins, minerals, dietary supplements, or herbs while I get chemotherapy?

Some of these products can change how chemotherapy works. For this reason, it is important to tell your doctor or nurse about all the vitamins, minerals, dietary supplements, and herbs that you take before you start chemotherapy. During chemotherapy, talk with your doctor before you take any of these products.

Your doctor will give you physical exams and medical tests (such as blood tests and x-rays). He or she will also ask you how you feel.

You cannot tell if chemotherapy is working based on its side effects. Some people think that severe side effects mean that chemotherapy is working well. Or that no side effects mean that chemotherapy is not working. The truth is that side effects have nothing to do with how well chemotherapy is fighting your cancer.

It is hard to say how much chemotherapy will cost. It depends on:

• The types and doses of chemotherapy used
• How long and how often chemotherapy is given
• Whether you get chemotherapy at home, in a clinic or office, or during a hospital stay
• The part of the country where you live

Does my health insurance pay for chemotherapy?

Talk with your health insurance plan about what costs it will pay for. Questions to ask include:

• What will my insurance pay for?
• Do I or does the doctor's office need to call my insurance company before each treatment for it to be paid for?
• What do I have to pay for?
• Can I see any doctor I want or do I need to choose from a list of preferred providers?
• Do I need a written referral to see a specialist?
• Is there a co-pay (money I have to pay) each time I have an appointment?
• Is there a deductible (certain amount I need to pay) before my insurance pays?
• Where should I get my prescription drugs?
• Does my insurance pay for all my tests and treatments, whether I am an inpatient or outpatient?

How can I best work with my insurance plan?

• Read your insurance policy before treatment starts to find out what your plan will and will not pay for.
• Keep records of all your treatment costs and insurance claims.
• Send your insurance company all the paperwork it asks for. This may include receipts from doctors' visits, prescriptions, and lab work. Be sure to also keep copies for your own records.
• As needed, ask for help with the insurance paperwork. You can ask a friend, family member, social worker, or local group such as a senior center.
• If your insurance does not pay for something you think it should, find out why the plan refused to pay. Then talk with your doctor or nurse about what to do next. He or she may suggest ways to appeal the decision or other actions to take.

Cancer clinical trials (also called cancer treatment studies or research studies) test new treatments for people with cancer. These can be studies of new types of chemotherapy, other types of treatment, or new ways to combine treatments. The goal of all these clinical trials is to find better ways to help people with cancer.

Your doctor or nurse may suggest you take part in a clinical trial. You can also suggest the idea. Before you agree to be in a clinical trial, learn about:

• Benefits. All clinical trials offer quality cancer care. Ask how this clinical trial could help you or others. For instance, you may be one of the first people to get a new treatment or drug.
• Risks. New treatments are not always better or even as good as standard treatments. Even if this new treatment is good, it may not work well for you.
• Payment. Your insurance company may or may not pay for treatment that is part of a clinical trial. Before you agree to be in a trial, check with your insurance company to make sure it will pay for this treatment.

• Make a list of your questions before each appointment. Some people keep a "running list" and write down new questions as they think of them. Make sure to have space on this list to write down the answers from your doctor or nurse.
• Bring a family member or trusted friend to your medical visits. This person can help you understand what the doctor or nurse says and talk with you about it after the visit is over.
• Ask all your questions. There is no such thing as a stupid question. If you do not understand an answer, keep asking until you do.
• Take notes. You can write them down or use a tape recorder. Later, you can review your notes and remember what was said.
• Ask for printed information about your type of cancer and chemotherapy.
• Let your doctor or nurse know how much information you want to know, when you want to learn it, and when you have learned enough. Some people want to learn everything they can about cancer and its treatment. Others only want a little information. The choice is yours.
• Find out how to contact your doctor or nurse in an emergency. This includes who to call and where to go.

Questions to Ask

About My Cancer

• What kind of cancer do I have?
• What is the stage of my cancer?

About Chemotherapy

• Why do I need chemotherapy?
• What is the goal of this chemotherapy?
• What are the benefits of chemotherapy?
• What are the risks of chemotherapy?
• Are there other ways to treat my type of cancer?
• What is the standard care for my type of cancer?
• Are there any clinical trials for my type of cancer?

About My Treatment

• How many cycles of chemotherapy will I get?
• How long is each treatment?
• How long between treatments?
• What types of chemotherapy will I get?
• How will these drugs be given?
• Where do I go for this treatment?
• How long does each treatment last?
• Should someone drive me to and from treatments?

About Side Effects

• What side effects can I expect right away?
• What side effects can I expect later?
• How serious are these side effects?
• How long will these side effects last?
• Will all the side effects go away when treatment is over?
• What can I do to manage or ease these side effects?
• What can my doctor or nurse do to manage or ease these side effects?
• When should I call my doctor or nurse about these side effects?

At some point during chemotherapy, you may feel:

• Anxious
• Depressed
• Afraid
• Angry
• Frustrated
• Helpless
• Lonely

It is normal to have a wide range of feelings while going through chemotherapy. After all, living with cancer and getting treatment can be stressful. You may also feel fatigue, which can make it harder to cope with your feelings.

How can I cope with my feelings during chemotherapy?

• Relax. Find some quiet time and think of yourself in a favorite place. Breathe slowly or listen to soothing music. This may help you feel calmer and less stressed.
• Exercise. Many people find that light exercise helps them feel better. There are many ways for you to exercise, such as walking, riding a bike, and doing yoga. Talk with your doctor or nurse about ways you can exercise.
• Talk with others. Talk about your feelings with someone you trust. Choose someone who can focus on you, such as a close friend, family member, chaplain, nurse, or social worker. You may also find it helpful to talk with someone else who is getting chemotherapy.
• Join a support group. Cancer support groups provide support for people with cancer. These groups allow you to meet others with the same problems. You will have a chance to talk about your feelings and listen to other people talk about theirs. You can find out how others cope with cancer, chemotherapy, and side effects. Your doctor, nurse, or social worker may know about support groups near where you live. Some support groups also meet online (over the Internet), which can be helpful if you cannot travel.

Talk to your doctor or nurse about things that worry or upset you. You may want to ask about seeing a counselor. Your doctor may also suggest that you take medication if you find it very hard to cope with your feelings.

It is normal to have a wide range of feelings while going through chemotherapy. After all, living with cancer and getting treatment can be stressful.

Side effects are problems caused by cancer treatment. Some common side effects from chemotherapy are fatigue, nausea, vomiting, decreased blood cell counts, hair loss, mouth sores, and pain.

What causes side effects?

Chemotherapy is designed to kill fast-growing cancer cells. But it can also affect healthy cells that grow quickly. These include cells that line your mouth and intestines, cells in your bone marrow that make blood cells, and cells that make your hair grow. Chemotherapy causes side effects when it harms these healthy cells.

Will I get side effects from chemotherapy?

You may have a lot of side effects, some, or none at all. This depends on the type and amount of chemotherapy you get and how your body reacts. Before you start chemotherapy, talk with your doctor or nurse about which side effects to expect.

How long do side effects last?

How long side effects last depends on your health and the kind of chemotherapy you get. Most side effects go away after chemotherapy is over. But sometimes it can take months or even years for them to go away.

Sometimes, chemotherapy causes long-term side effects that do not go away. These may include damage to your heart, lungs, nerves, kidneys, or reproductive organs. Some types of chemotherapy may cause a second cancer years later. Ask your doctor or nurse about your chance of having long-term side effects.

What can be done about side effects?

Doctors have many ways to prevent or treat chemotherapy side effects and help you heal after each treatment session. Talk with your doctor or nurse about which ones to expect and what to do about them. Make sure to let your doctor or nurse know about any changes you notice - they may be signs of a side effect.