Befor you Select your Treatment Program

As an active participant in your health care, you will want to become informed about side effects before you select your treatment program so that you are aware of:

1. What side effects commonly occur with which type of treatment or drug regimen.
2. What is the likelihood that you will have those side effects and how mild or severe they might be.
3. Whether the benefits of a specific treatment outweigh the potential side effects.
4. Which side effects are most compatible with your lifestyle and expectations for your lifestyle during cancer treatment.

Above all, in many instances in the treatment of lung cancer, you do have a choice about the type of chemotherapy drugs, radiation therapy, and/or surgery you want to receive. This is probably one of the most important conversations you will have with your oncologist as you discuss your disease, its prognosis, and treatment options.

Nearly every form of cancer treatment has some side effects. The incidence and management of side effects is as unique as you are. You may have only a few of those side effects associated with the therapy you are receiving. Being aware of what might happen can reassure you that certain side effects are “normal” and can help prepare you for what to do if they occur. Awareness can also help you to avoid certain side effects by selecting a different treatment course or by preparing you and your physician to be proactive in taking medications (such as for nausea and vomiting) that will prevent or ease the impact of the side effect itself.

It is always best to contact your physician to report any concerns about how you are reacting to either the disease or its treatments. It is YOUR responsibility to report side effects to your physician and/or nurse.

The most common side effects of treatment for lung cancer can include, but are not limited to, fatigue, peripheral neuropathy, difficulty breathing, sore throat, coughing, nausea, diarrhea, mouth sores, and hair loss. Some other important and often difficult side effects to cope with include infection, pain, and emotional distress such as anxiety and depression. The good news is that there are specific approaches you can take to not only manage, but also, in some circumstances, even prevent these challenging and worrisome side effects.

It Is Important That Your Treatment Remains on Schedule.

You want to get through your lung cancer treatment as quickly and successfully as possible. Having to postpone your treatment due to a low white blood cell count or other distressing side effects can leave you feeling disappointed, anxious, and fearful. Whatever treatment you choose may have some side effects. Not only will managing those side effects improve the way you feel during treatment, it could make a difference in the outcome of your treatment as well.

Potential Side Effects & Helpful Hints

Some of the following side effects may be associated with various types of lung cancer treatment, including chemotherapy, radiotherapy, surgery, and others. Other side effects may be related to the effects of the disease itself, such as breathing problems. It is important to communicate with your physician and nurse about any of these side effects or any others not mentioned. Just because the following common side effects are listed here (alphabetically) does not mean you will experience them.

Breathing Problems

It is not uncommon for lung cancer patients to have breathing problems. Things that can affect breathing include the tumor itself, infection, and/or certain chemotherapy drugs that can affect the heart and lungs. Removal of lung tissue and damage to nearby tissue can also cause breathing problems.

• Call your doctor immediately if you have chest tightness, pain, fever, or trouble breathing.
• Oxygen therapy from either portable tanks of pressurized oxygen or an electronic unit that plugs  into a household electrical outlet can be helpful.
• Corticosteroid therapy may also provide relief for breathing difficulties.
•  If you are using an inhaler, it is important to use it as prescribed by your doctor. Inhalers need to be used consistently over time to produce symptom relief.

Bruising or Bleeding

Bruising or bleeding during or following chemotherapy or radiotherapy might be caused by an inadequate number of platelets because some treatments can suppress the bone marrow where blood cells (white blood cells, red blood cells, and platelets) are made. See “Low Platelet Count” for more information.

Constipation

Certain drugs, including pain medications, can cause constipation. If you are receiving chemotherapy and/or radiation and have mild or infrequent constipation or other bowel problems, talk with your doctor and consider some of the following suggestions:

• Drink plenty of fluids. Warm and hot fluids are especially good to help loosen the bowel.
• Eat high-fiber foods, such as bran, whole wheat breads and cereals, vegetables, and popcorn.
• Try to be as physically active as possible.
• Enemas should not be used without consulting your doctor.
• Stool softeners may be helpful but should not be used without first talking to your physician.
• Call your doctor immediately if you have been constipated for more than 3 days or you have difficulty breathing. Fecal impaction can be fatal and should be treated immediately.

Diarrhea

Diarrhea is an increase in the liquidity and frequency of stool. Certain types of cancer treatment including chemotherapy can cause diarrhea as dying cells are shed from the intestine. Other causes of diarrhea can include infection, drug-induced reactions, and diet alterations.

Some helpful tips for managing diarrhea:

• Eat smaller amounts of food, but eat more often.
• Avoid high-fiber foods and try the BRAT diet: bananas, rice, unspiced applesauce, and toast. Eat low-fiber foods such as mashed potatoes without the skin, noodles, cottage cheese, and pureed vegetables.
• Avoid fried, greasy, or spicy foods.
• Avoid caffeinated products such as tea, coffee, and soda.
• Avoid milk and milk products.
• Eat potassium-rich foods and drink plenty of fluids to replace what you lose through diarrhea.
• Talk to your doctor before taking any over-the-counter diarrhea medicine.
• Contact your doctor if you have severe diarrhea lasting more than 2-3 days or immediately if it is combined with fever and/or severe pain.

Fatigue

Fatigue is an overwhelming and consistent lack of energy that is not related to exertion or relieved with a good night’s sleep. Fatigue is one of the most significant long-term side effects of cancer treatment and is almost universally experienced by people undergoing cancer treatment. The most common cause for fatigue, during or following cancer treatment (especially chemotherapy), is a low red blood cell count, also known as anemia. Fatigue may also be related to an iron-deficiency anemia and can be treated with iron supplements or enhanced diet. Fatigue may also be caused by emotional distress such as depression and anxiety. Generally, fatigue will begin to subside within a few months after the end of treatment.

• Talk to your doctor about how your existing medical condition and treatment may be causing you to feel fatigued.
• If you have low hemoglobin (concentration of red blood cells in the blood), talk to your doctor about red blood cell growth factors that stimulate the production of red blood cells and reduce fatigue.
• Get plenty of rest. Take small naps throughout the day.
• Do some form of physical activity, starting slowly at first, and working up to a level that is comfortable.
• Drink plenty of water during the day.
• Avoid caffeine or tobacco in the evening.
• Practice conserving your energy by being willing to ask for help from family and friends to help with chores, errands, or other tasks.
• Consider a gentle exercise or stress-reduction program such as Tai Chi or yoga.

Hair Loss (Alopecia)

Radiation therapy and many chemotherapy drugs can cause hair loss, or alopecia. Some chemotherapy drugs cause people to lose some of their hair, and some cause you to lose it all, including body hair, eyebrows, and eyelashes. Talk to your doctor about what you can expect regarding hair loss with your specific treatment regimen.

Some helpful hints include:

• Use mild shampoos and soft hairbrushes.
• Use low heat when drying your hair.
• Buy scarves, wigs or hats, or a scalp prosthesis.
• When buying a wig, try to do so before you lose your hair so the hair stylist can more easily match your color and preference.
• Do not dye your hair or get a permanent or body wave.
• Use sunscreen and wear a hat or scarf to protect your scalp from the sun.
• Women and men undergoing cancer treatments should call the local American Cancer Society to see if a Look Good, Feel Better program is being held in the area.

Heart and Cardiovascular Changes

Surgery and other common chemotherapy drugs for lung cancer may cause problems with heart function. Some symptoms may include chest tightness or pain, difficulty breathing, unusually slow or rapid heartbeat, or numbness in the left arm or shoulder.

• When deciding what type of chemotherapy might be best for you, talk with your doctor about the potential adverse effects that certain chemotherapy drugs could have on your heart.
• An echocardiogram, stress electrocardiogram, or MUGA test may be done to determine your heart function before treatment is started.
• Contact your physician immediately if you experience chest pain, changing heartbeat, or numbness in the left arm or shoulder.

Infection

Certain chemotherapy drugs have a more dramatic effect than others on the immune system in destroying not only the cancer cells, but healthy blood cells as well. This can cause a reduction in the number of white blood cells (called neutropenia) that help fight infection. Since a serious infection can be potentially life-threatening requiring hospitalization and the delay of scheduled treatment, prevention and control are the primary tools to manage this serious side effect. Infection can occur after surgery, bronchoscopy, chemotherapy, and/or radiation therapy.

• Talk to your doctor PRIOR to starting chemotherapy to discuss the risk of this potential side effect as well as medications, such as white cell growth factors, that could help you avoid  prolonged periods of low white blood cell counts (neutropenia).
• While in treatment, keep track of your white blood cell count when you have your complete blood count (CBC) done at clinic visits.
• Call your doctor immediately if you have a temperature of 100.4 degrees or higher, pain,  redness, swelling or pus at a surgical or central line site, severe chills, pain while urinating, or trouble breathing.
• Practice good hand-washing techniques and avoid crowds or people who might be infected with colds, flu, chicken pox, etc.
• Avoid lung contaminants such as tobacco or wood smoke from a fireplace as there is some evidence that exposure may increase the risk of infection in an immune-suppressed patient.

Loss of Appetite

Chemotherapy and radiation can affect your taste buds. The stress of the cancer experience can also affect your interest in eating. Adequate nutrition is an important part of the body’s recovery from cancer and yet it is often a challenge for patients in cancer treatment. Many cancer centers have a registered dietitian available to assist you with eating concerns [See Maximizing Your Health & Well-Being].

Some helpful hints include:

• Eat small meals or snacks whenever you want, rather than eating 3 meals a day.
• Vary your diet. Try new foods and recipes.
• Use liquid nutritional products that are high in calories and protein.
• Try to take in at least 4 ounces of protein each day.
• Snack on nutrition bars or power bars.
• A walk before meals may make you feel hungrier.
• Arrange to eat with family and friends, or watch TV while eating if you are alone.

Low Platelet Count

Certain types of chemotherapy and/or radiation can also cause bruising or bleeding because they may cause you to have a lowered number of platelets. Platelets are the blood cells that clot your blood. The condition of low platelets is called thrombocytopenia. Bleeding can occur unexpectedly following surgery or bronchoscopy.

Some helpful hints for managing low platelets include:

• You may want to keep track of your platelet count when you have your complete blood count (CBC) done during clinic visits. Ask your doctor or oncology nurse if this is a side effect you should be concerned about.
• Report any bruising or bleeding to your doctor immediately. You may need a platelet transfusion or medication that stimulates early growth of platelet cells in the bone marrow.
• Use a soft toothbrush to clean your teeth.
• Clear your nose or sinuses by blowing gently into a soft tissue.
•  Take care not to cut or nick yourself when using scissors, needles, knives, or tools.
• Avoid contact sports and other activities that might result in injury.

Mouth Sores/Gum and Throat Problems

Mouth sores and gum and throat problems can occur 2-5 days after chemotherapy administration, persisting up to 14 days, or occur 1-2 weeks after radiation therapy is started. The intensity and duration of these side effects depend on the type and dosage of the drug or the depth or frequency of the radiation. Smokers are more likely than non-smokers to develop mouth sores. This side effect can range from mild discomfort to painful lesions, infection, and bleeding.

• See your dentist before starting chemotherapy to have your teeth cleaned and to take care of problems such as gum disease, cavities, and abscesses.
• If you are on oxygen, ask for a humidifier bottle to attach to the oxygen line to decrease dryness.
• Brush your teeth and gums gently after every meal using a soft toothbrush. Rinse the toothbrush after each use.
• Use toothpaste designed for children, as it is less abrasive than adult toothpaste.
• Eat foods that are cold, cool, or at room temperature.
• Rinse your mouth several times a day with salt water (1 teaspoon salt per 1 quart water).
• Avoid salty, tart, acidic, spicy and/or coarse foods.
• Drink through a straw to bypass mouth sores.
• Limit or eliminate alcohol and tobacco, both of which irritate tissues in the mouth.
• If you have a bad taste in your mouth, suck on hard candies.
• Severe mouth or throat pain can be treated with pain medicine, or your doctor can prescribe a special mouthwash that contains a painkiller, an antibiotic, and an anti-fungal agent.

Nausea and Vomiting

Many people assume that nausea and vomiting is an expected and unpreventable part of cancer treatment. Fortunately, significant advances have occurred in recent years that have revolutionized cancer therapy so that this side effect can be controlled effectively. This has not only improved quality of life for cancer patients, but has made it possible for patients to tolerate even more aggressive treatments for their disease. There are different treatments for nausea and vomiting depending on when it is likely to occur and what is likely to cause it.

Chemotherapy-induced vomiting can be divided into 3 types: acute, delayed, and anticipatory. Acute nausea and vomiting usually occurs within 24 hours of the chemotherapy treatment. Delayed nausea or vomiting generally begins 24 hours after the administration of chemotherapy and can persist for 6-7 days. Anticipatory nausea or vomiting is thought to be a learned response and typically occurs when the patient has experienced nausea and vomiting in previous treatment sessions.

Not all chemotherapy causes nausea and vomiting. Other cancer treatments such as surgery and radiation may also cause this side effect. For example, nausea may be a side effect of radiation to the esophagus or upper body. It is important, however, that nausea and vomiting be controlled, not just to improve quality of life, but also to keep you hydrated, rested, and relaxed. There are excellent medications available today that effectively control nausea and vomiting with most cancer treatments.

When receiving chemotherapy drugs for lung cancer that are known to have a higher risk for acute nausea and vomiting (within 24 hours of treatment), the American Society of Clinical Oncology (ASCO) recommends the use of what is called “antiemetic” medication, often in combination with another medicine called a “steroid,” before chemotherapy. Antiemetic medications include such medications as ondansetron (Zofran®), granisetron (Kytril®), or dolasetron (Anzemet®) often combined with a steroid like dexamethasone. Doses of these medications are modified according to how much risk a specific chemotherapy drug has for causing nausea and vomiting.

The FDA has approved ondansetron (Zofran®) for the prevention of nausea and vomiting associated with surgery, chemotherapy, and radiation. It is available as an intravenous solution, an oral liquid, a single-dose tablet, and an orally disintegrating tablet for ease of use in patients who may experience mouth sores or esophagitis or have difficulty swallowing. Ondansetron (Zofran®) is the only FDA-approved medication in its class that can be administered for 1-2 days after any chemotherapy and/or radiotherapy that is known to have a moderately high risk for causing nausea and vomiting.

Granisetron (Kytril®) is available as an intravenous solution and oral tablet and is approved by the FDA for prevention of nausea and vomiting associated with chemotherapy and radiation. The FDA has also approved the use of dolasetron (Anzemet®) for the prevention of nausea and vomiting associated with chemotherapy and surgery. However, it should be used with caution in patients who have, or are at risk, for certain heart problems. Dolasetron is available as an intravenous solution and as an oral tablet.

As with any medication, there are potential side effects with antiemetic therapy. Some of the possible side effects in all 3 of the medications discussed above include diarrhea, constipation, and headache.

Some helpful hints in managing or preventing nausea and vomiting include:

• Discuss with your oncologist, surgeon, or radiologist the risk that the chemotherapy or other cancer treatment you are receiving will cause nausea and vomiting as well as your desire to  actively prevent or control it with medication, if necessary, before treatment starts.
• Sometimes a steroid, such as dexamethasone, is used for 3-4 days after chemotherapy to lessen  any development of delayed nausea and vomiting.
• Prevention works well, so take anti-nausea medications on time, before symptoms appear.
• Avoid large meals. Instead, eat small meals throughout the day.
• Avoid fried, fatty, and sweet foods.
• Chew food well for easier digestion. Eat and drink slowly.
• Suck on ice cubes, mints, or tart candies. (If you have mouth sores, don’t eat tart candies.)
• Eat foods that are served at room temperature.
• If nausea is a problem in the morning, eat dry foods like cereal, toast, and crackers.
• Rest in a chair after eating, but don’t lie flat until at least 2 hours after you’ve finished your meal.
• Breathe relaxed and slowly; use relaxation techniques.
• Distract yourself by watching television, talking to friends and family, or listening to music.
• Try drinking peppermint or ginger tea.
• Call your doctor immediately if nausea and vomiting are combined with fever or any other symptoms described in the section “Infection.”
• Anti-nausea medication is generally covered by insurance during cancer treatment. If you do not have insurance, some manufacturers have patient assistance programs to help you obtain medications.

Pain

Pain can be a common short- or long-term side effect of lung cancer, and its treatment includes surgery, radiation, and certain chemotherapy agents. Some drug therapies can cause jaw, hand, foot, back, joint, or stomach pain. Suffering in pain is one of the greatest myths and fears that people associate with cancer. There are many effective pain management tools, such as long-acting medications, behavior modification, pain control devices, or relaxation training.

• Always report pain to your doctor. Communication about pain is always the first step toward controlling it.
• Take pain medication as prescribed by your doctor. If it becomes less effective or stops working, be sure to talk to your doctor about adjusting your pain medication.
• Consider consulting a pain specialist or pain clinic if you continue to have problems managing your pain.
• As a cancer patient, you have the right to have your pain relieved no matter what its cause or its severity.

Peripheral Neuropathy or Nerve Changes

Certain chemotherapy drugs such as the platinum-based drugs can cause peripheral neuropathy, which is a tingling, burning, weakness, or numbness in the hands or feet that can make it difficult to handle objects or even to manipulate your fingers. These same chemotherapy agents can also cause muscle weakness, hearing loss, ringing in the ears, difficulty walking, or seizures. Any of these latter symptoms should be reported to your physician immediately.

• Discuss the risk of these side effects with your oncologist PRIOR to making decisions about your treatment regimen.
• If you experience peripheral neuropathy, be careful when grasping sharp or hot objects.
• Use handrails when going up and down stairs.
• Always wear shoes or house slippers with rubber soles to prevent falls.
• Remove throw rugs or other objects in your home that you might trip on.
• Avoid exposing your fingers and toes to very hot or very cold temperatures.

Radiation Fibrosis

Radiation fibrosis is the formation of fibrous scar tissue within the lung, and it is caused by the immune system’s reaction to radiation. This condition may be temporary or could possibly develop months or years after radiotherapy ends. Fibrosis may interfere with breathing and general comfort.

• Symptoms may include a dry mouth or sore throat and difficulty swallowing or breathing.
• Talk to your radiation oncologist about how to minimize your risk of this side effect.

Sexual and Reproductive Concerns

Many people have indicated that after being diagnosed with cancer, they experience a change in their interest and desire for sexual activity, or if becoming a parent is still an issue, they worry about the impact of cancer therapy on fertility. If you are concerned, you should raise these issues with your doctor and ask what effect your cancer treatment may have on your sexual or reproductive functioning before you start therapy, if at all possible.

Some of the options for coping with a change in sexual or reproductive functioning include the following:

• It is very normal to not be interested in sexual activity due to the emotional stress of cancer, fatigue, or pain. Give yourself and your partner some time to adjust to the many changes in your body and your life.
• If concerns about sexual or reproductive functioning become more problematic for you, seek counseling (either individual or as a couple) to get help with sexual or reproductive issues, including anxiety about sexual functioning, body image issues, and feelings of loss, depression, or sadness.
• It is recommended that men use condoms for sexual intercourse 24-36 hours post-chemotherapy. Women should use any effective method to avoid pregnancy while receiving chemotherapy.
• If your platelets are low, you may want to refrain from intercourse until your counts return to a higher level.
• Female lung cancer patients who are treated with chemotherapy or cranial radiation may experience temporary or permanent menopause. Hot flashes, loss of libido, and mood swings can be common side effects. Ask your oncologist for recommendations to relieve any of these symptoms.
• If becoming a parent is a future concern and lung cancer treatment is not urgent, harvesting  sperm or ova (eggs) might be an important option to discuss with your physician BEFORE taking certain types of chemotherapy that are known to cause infertility.
• The American Cancer Society has two booklets on sexuality and cancer, one for men and one for women, which can be obtained by calling 1-800-ACS-2345.

Skin Problems

A variety of skin problems, including pain, redness, scaling, dryness, sun sensitivity, and hives can result from radiation, photodynamic therapy, and certain chemotherapies.

• Use skin care products, especially ones containing lanolin or aloe, to prevent chapped and hardened skin and provide relief.
• Call your doctor about skin reactions that you are concerned about to obtain the most effective treatment.

For More Information:

1. Gates, R. and Fink, R. Oncology Nursing Secrets: Questions & Answers About Caring for Patients With Cancer. Hanley & Belfus, 1997.
2. Johnston L. Lung Cancer: Making Sense of Diagnosis, Treatment and Options. O’Reilly, 2001.
3. National Cancer Institute. “Chemotherapy and You: A Guide to Self-Help During Treatment.” National Institute of Health Publication. 94-1136; Revised July 1993.
4. Schover, PhD L. Sexuality and Fertility After Cancer. John Wiley & Sons; 1997.
5. Scott,W., MD. Lung Cancer: A Guide to Diagnosis and Treatment. Addicus Books, 2001.