Fact Sheet 12

Chemotherapy

Being prescribed chemotherapy can be frightening, but the treatment doesn't mean the same thing for everybody.

Chemotherapy (sometimes called chemo) simply means drug treatment and aims to cure cancer or relieve any symptoms that cancer can cause. It can be used by itself, with surgery, with radiotherapy or both. Your doctor will discuss the best options with you and your family if you wish.

How does chemotherapy work?

Chemotherapy either kills cancer cells or stops them dividing. In the same way that different bacteria are sensitive to different antibiotics, different cancers are sensitive to different types of chemotherapy.

Chemotherapy reaches the cancer cells through the bloodstream and destroys them as they’re in a dividing phase (two cells divide into four, four cells divide into eight, etc). Not all cancer cells are in the dividing stage, some will be in the resting stage and chemotherapy is unable to destroy them.

Over the next few months, as you have more chemotherapy treatments, the cancer cells that were resting will start to divide. This is why a number of chemotherapy treatments called cycles make up a course of treatment.

How is chemotherapy given?

Chemotherapy can be given in a number of different ways:

• By injection into a vein or a muscle, or the tissue just under the skin.
• As an infusion (drip) through a small plastic needle called a cannula. This way is used for large amounts of fluid which need to run over a few hours or days.
• As a continuous infusion using a small pump that you can carry around with you. This is usually given via a catheter which is kept in place either in your arm (called a PICC), or in your chest using a soft tube (called a central venous catheter).
• As tablets. Your chemotherapy nurse will tell you when to take them and when to stop.
• Into a body cavity (for example the bladder or tummy).
• As an ointment applied directly to your skin.
• By a lumbar puncture (inserting a needle into your spine) so that the chemotherapy reaches the fluid which surrounds your brain.

Your doctor and chemotherapy team will discuss with you the best way to give you your treatment.

The side-effects of chemotherapy

Chemotherapy can produce different reactions in different people and side-effects can change from treatment to treatment. Since most side-effects are temporary, they will gradually disappear when your treatment is complete. There is no connection between the extent of side-effects you experience and the effect of the chemotherapy on your cancer. In other words, if you don’t have any side-effects it doesn’t mean that the treatment is not working.

Some side-effects can be tiresome, but you and your doctor must weigh this against the benefits of treatment. It's important that you talk about any side-effects and how you are managing with your chemotherapy team as there are many ways your treatment team can help.

The main areas affected by chemotherapy are those where normal cells divide quickly:

• Bone marrow
• Mouth
• Digestive system (stomach and bowels)
• Hair
• Skin
• Reproductive organs (ovaries and testes)

Effects on bone marrow

Bone marrow is a sponge-like substance that produces blood cells in the hollow spaces of bones. It's sensitive to most types of chemotherapy but the following blood cells are especially sensitive:

• White blood cells help your body to fight infection. If they are low you will be more at risk of developing infections. While you are having chemotherapy, you should avoid people with infections such as flu or chicken pox.
• Platelets help your blood clot, if they’re low you may notice that you bruise easily, pin prick type reddish/purple spots on your skin, nose bleeds or bleeding gums, or pass blood when you go to the toilet.
• Red blood cells carry oxygen to all the cells in the body. A lack of red blood cells can cause anaemia, which may lead to shortness of breath and tiredness.

Effects on the mouth

Some chemotherapy drugs can make your mouth dry and sore and sometimes you may develop mouth ulcers.

Effects on the digestive system

• Feeling sick and vomiting may be a problem for some patients, but not all chemotherapy drugs affect people in this way
• Diarrhoea or constipation can be caused by some chemotherapy drugs

Effects on the hair

• Not all chemotherapy drugs cause the hair to fall out, your doctor or nurse will tell you if they expect it to happen to you.
• Sometimes hair may thin slightly, and some people don’t notice, but other chemotherapy drugs can cause partial or complete hair loss. The amount of hair loss will depend on the drug and the dose and usually starts within two or three weeks after treatment. As the hair begins to fall out, there may be some tenderness in the scalp around the hair follicles.
• Sometimes other hair on the body will fall out, including eyelashes, eyebrows and facial hair.

Effects on the skin

• Some chemotherapy drugs can make the skin feel dry and itchy, or it may become sensitive to sunlight
• It can develop darker patches, especially over the veins used for chemotherapy
• Nails may discolour and white ridges may appear for a time, or they may split and not grow at their usual rate

Skin Changes Caused by Targeted Chemotherapies

What are targeted therapies?
Many of the newer chemotherapy drugs used to treat cancer are called targeted therapies. These drugs act on certain parts of cancer cells to block the growth and spread of cancer. They work by affecting the processes that make normal cells become cancer cells and cause tumors to grow. The goal of targeted therapy is to destroy cancer cells while causing little or no damage to normal, healthy cells. Targeted therapies can be used to treat certain types of many different cancers, including lung, pancreatic, head and neck, liver, colorectal, breast and kidney cancers.

Why do targeted therapies cause skin changes?
Targeted therapies help stop cancers from getting bigger, but also cause problems with the skin. These therapies target the epidermal growth factor receptor (EGFR) protein. EGFR has been found in larger than normal amounts on the surface of cancer cells from some types of tumors. EGFR tells the cancer cells to grow and divide. The problem is that normal skin cells also have a lot of EGFR. So drugs that target or block EGFR often affect these cells by turning off the signal for them to grow and making it harder for them to retain moisture.

Some of the newer drugs target other proteins, such as vascular endothelial growth factor receptor (VEGFR) and platelet-derived growth factor receptor (PDGFR). These proteins help tumors maintain their blood supply, but they also seem to be important to the very small blood vessels in the hands and feet. Damage to these tiny blood vessels can cause hand-foot syndrome.

What kind of skin changes can targeted therapies cause?
Rash - The most common skin change is a rash. The risk of getting the rash and how severe it is depends on the type of cancer and the type and dose of the targeted therapy drug used to treat it.  The rash is mild for most people. It often looks a lot like acne and shows up on the scalp, face, chest, and upper back. In severe cases it can affect other parts of the body.  The rash most often starts as skin redness and swelling, and is often worst within the first few weeks of treatment. By about the 4th week of treatment, the skin usually crusts and gets very dry and red. In the weeks after that, round, flat or raised red spots and "whitehead" pimples with pus in the center often appear. The rash can be itchy. It may improve or stay about the same during the rest of treatment, but it should completely go away about a month after treatment is stopped.  The rash can be very distressing and cause self-esteem problems. It can also lead to infections, and it may be painful.

Dry skin - The skin can become very dry and scaly and may even crack open. This can happen on its own or with the rash. When it happens with the rash it tends to be worse.

Itching - Many of the skin changes, like rash or dryness, can cause itching. Steps to prevent and treat skin changes, as discussed below, can help with itching. Some people may need to take medicine by mouth, such as diphenhydramine (Benadryl®), to get relief.

Red, sore cuticles (the areas around the fingernails) - Some targeted therapies may cause swollen, red, open, and painful skin sores around the fingernails and toenails. This most often happens to the big toes and thumbs.

Hand-foot syndrome - Hand-foot syndrome (HFS) has been linked to many cancer treatment drugs, including some targeted therapies. The cause of this syndrome is not known for sure. It may have to do with damage to the tiny blood vessels in the hands and feet, or with the drugs themselves leaking out of the blood vessels and causing tissue damage. A painful sensitivity of the hands and feet is the earliest symptom of HFS. Then, redness and swelling start in the palms of the hands and the soles of the feet. This redness looks a lot like sunburn and may blister. In severe cases, the blisters can open up and become sores. The affected skin also can become dry and peel, and you may feel burning, tingling, or numb sensations. HFS can be painful and can affect your ability to walk and carry out normal activities. If it becomes severe, pain medicines may be needed. It is important to let your doctor know if you are having any symptoms of HFS -- even if they are mild. Treating HFS early can help prevent severe cases. Like the other skin changes discussed, it can be treated, and there are things you can do to try to prevent it.

Changes in hair or skin color - Some of the newer drugs can cause the skin or hair to turn a yellowish color during treatment. This typically goes away once treatment is finished.

What should I do if I have skin changes?
It is very important to tell your doctor or nurse about any rashes or skin changes you notice. Left untreated, the rash can get worse and lead to infection, as well as the need to hold or even stop treatment. Do not treat your skin with over-the-counter medicines or stop taking your targeted therapy without talking to your doctor first.
Your doctor may give you a skin cream or a medicine you take by mouth to treat the skin changes you have. Use theses medicines the way the doctor tells you to and start them right away. Let your health care team know if your skin is not getting better after 2 weeks of treatment.

Be sure to let your doctor or nurse know if:

•  Your skin is dry, flaking, or cracked. Moisturizing cream may help with this.
• Your skin is itchy. There are creams and gels you can use to ease itchiness. There are also some medicines you can take by mouth to try to stop the itching.
• The area around your fingernails or toenails becomes sore or red. Creams and soaks can help with this.

There are some things you can do to help prevent skin changes or at least to try to keep them under control. You should start to do them as soon as targeted therapy treatment begins or before any problems start. Your doctor may suggest you do the following:

• Use a mild soap or body wash that does not contain alcohol, perfume, or dye.
• Take baths instead of showers, and try oatmeal bath products to soothe the skin. 
• Bathe with cool or lukewarm (instead of hot) water.
• Moisturize your skin 2 times a day with a thick, alcohol-, perfume-, and dye-free cream. Do this right after bathing while your skin is still damp.
• Do not use laundry detergents with strong perfumes.
• Stay out of the sun as much as possible.
• If you will be outside, use a sunscreen with SPF of at least 30 and zinc oxide or titanium dioxide at least 1 to 2 hours before going out; wear cotton clothing and a hat, too.
• Though the rash may look like acne, do not use acne treatment medicines on it -- they can dry it out and make it worse.  
• Do not wear tight shoes.
• Gel shoe inserts may help if soles of your feet are tender.
• Some makeup brands, can cover the rash without making it worse.

Effects on fertility

• Not all chemotherapy drugs cause infertility, which may be temporary or permanent, depending on the drugs used and the length of treatment.
• It may still be possible to become pregnant or father a child during chemotherapy treatment.
• Some drugs affect the ovaries in women and stop the production of eggs. This may bring on symptoms associated with the menopause such as irregular periods, or no periods at all, hot flushes and dryness of the skin and vaginal dryness.
• In men, chemotherapy drugs may reduce the number or quality of sperm produced, affecting the ability to father a child.
• There is no medical reason why you cannot continue with a sexual relationship whilst having chemotherapy, but some people find that other side-effects, such as tiredness, hair loss and feeling sick may make you feel less attractive to your partner. Other feelings, such as anger, anxiety or depression may also affect you.

Tiredness

• Many people having chemotherapy have extreme tiredness which is not relieved by rest. This is normal. Try to balance rest with gentle exercise and plenty of fresh air.
• Relaxation techniques may be helpful
• Warm baths before bed can relax you and help you to sleep.
• If you wake early, try not to get agitated and cross. Make a warm drink and maybe listen to some soothing music.

All patients treated with chemotherapy will be looked after by a team of healthcare professionals, who are there to support you and access specialist support if required

This article has been created from a number of different sources

Disclaimer

While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. All content within Pure and Gentle SkinCare is provided for general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. Pure and Gentle SkinCare is not responsible or liable for any diagnosis made by a user based on the content of Pure and Gentle SkinCare website or advisers.  Always consult your own GP if you're in any way concerned about your health as he or she will be able to advise in greater detail.