Chemotherapy - Side effects of chemotherapy

It is difficult to predict exactly what side effects you will experience while having chemotherapy. Different people react to treatment in different ways.

A small number of people have very few or even no side effects.

Many of the common side effects of chemotherapy are listed below, although it is unlikely that you will experience them all.

Your care team is there to help you cope with the physical and psychological side effects.

When to get urgent medical advice

While the side effects of chemotherapy can be distressing, most do not pose a serious threat to your health.

However, occasionally some side effects can be very serious. For example, if you have a rapid fall in white blood cells, you may be vulnerable to a serious infection.

People having chemotherapy for cancer of their blood cells or bone marrow are most at risk of serious infections. This is because this type of cancer will already have caused a reduction in white blood cell numbers.

Symptoms of a serious problem include:

a high temperature of 38°C (100.4°F) or above
shivering
breathing difficulties
chest pain
flu-like symptoms, such as muscle aches and pain
bleeding gums or nose
bleeding from other parts of the body that does not stop after applying pressure for 10 minutes
mouth ulcers that stop you eating or drinking
vomiting that continues despite taking anti-sickness medication
four or more bowel movements a day, or diarrhoea

If you have any of these symptoms, contact your care team immediately. Your care team should give you a card with 24-hour emergency phone numbers.

If you do not have a card or you cannot find it, call NHS 111.

Fatigue

Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue. You may feel generally tired or you may tire very easily after doing normal, everyday tasks.

While having chemotherapy, it is important to get plenty of rest. Do not carry out tasks or activities that you do not feel up to.

Light exercise, such as walking or yoga, can help boost your energy levels, but be careful not to push your body too hard.

If you are working, you may need to ask your employer to let you work part time until your chemotherapy has finished.

Read more about coping with the effects of tiredness and fatigue.

Contact your care team if you are suddenly significantly more tired than usual and you also feel out of breath. Extreme fatigue and shortness of breath can be a sign of anaemia (see below).

Nausea and vomiting

Nausea (feeling sick) and vomiting (being sick) are common side effects of chemotherapy. They affect around half of all people being treated.

If you have nausea and vomiting, you will be given medication to help control your symptoms. This type of medication is known as an anti-emetic.

Anti-emetics can be given in a number of different ways, including:

as a tablet or capsule, which can either be swallowed or placed under your tongue to dissolve
as an injection or drip
as a suppository, which is a capsule that you put into your rectum (back passage) so that it can dissolve
through a patch that you place on your skin

Continue to take your anti-emetics even if you do not feel sick because they will help prevent your symptoms from returning.

Side effects of anti-emetics include constipation, indigestion, problems sleeping (insomnia) and headaches.

There are several different types of anti-emetics. If the one you are taking doesn't work or if it causes too many troublesome side effects, contact your care team. There may be an alternative anti-emetic that works better for you.

Hair loss

Hair loss is a common side effect of some chemotherapy. It usually begins one to three weeks after the first chemotherapy dose and most people have significant hair loss after one to two months.

The scalp is most commonly affected, although hair loss can occur on other parts of the body. These include the arms, legs and face.

Hair loss can be very traumatic, particularly for women.

If you find hair loss particularly difficult to cope with, talk to your care team. They understand how distressing it can be and will be able to give you support and counselling.

You may also find it useful to read more about coping with hair loss.

You may decide that you want to wear a wig. For some people synthetic wigs are available free of charge on the NHS. Find out more about wigs on the NHS.

Hair loss due to chemotherapy is almost always temporary, and your hair should begin to grow back soon after your treatment has finished.

Around three-quarters of people no longer wear a wig or use a head covering six months after their chemotherapy treatment has finished.

Many people find that their newly grown hair is different than before. For example, it may be a different colour or it may be curlier or straighter than it used to be.

Cold cap

It may be possible to prevent hair loss due to chemotherapy by using a cold cap.

A cold cap looks similar to a bicycle helmet. It is designed to cool your scalp while you receive a dose of chemotherapy. In cooling the scalp, the cold cap reduces the amount of blood flow to the scalp. This reduces the amount of chemotherapy medication that reaches it.

Whether or not you can use a cold cap during treatment will depend on the type of cancer you have.

For example, a cold cap cannot be used if you have:

various types of leukaemia, such as acute lymphoblastic leukaemia, which is cancer of the blood cells and mainly affects children
multiple myeloma, which is a cancer that develops inside the bone marrow
non-Hodgkin's lymphoma, which is a cancer that develops inside the lymphatic system (a series of glands and vessels that help protect the body against infection)

With these types of cancers, there is a good chance that cancerous cells could have spread to your skull. Therefore, it would be too dangerous to cool your skull.

Cold caps work better with certain types of chemotherapy medications, and they may not always prevent hair loss.

Increased risk of infection

Chemotherapy can reduce you body's ability to fight infection, so you may be given a course of antibiotics to reduce your risk of developing an infection.

You will also need to take extra precautions to protect yourself against infection. For example, you should:

Have good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly.
Avoid contact with people who have an infection, such as chickenpox or flu.
Wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals.
Take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing.

Regular blood tests are often carried out during chemotherapy to identify when you are most vulnerable to infection.

You may be advised to take extra precautions, such as avoiding crowded places and using public transport at busy times.

Anaemia

Chemotherapy will lower the amount of red blood cells. These cells carry oxygen around the body. If your red blood cell count drops too low, your body will be deprived of oxygen and you will develop anaemia.

Symptoms of anaemia include:

tiredness – you will feel much more tired than the general level of fatigue associated with chemotherapy
lack of energy
shortness of breath (dyspnoea)
irregular heartbeat

If you have any of these symptoms, contact your care team as soon as possible.

You may need to have a blood transfusion to help increase the number of red blood cells. Alternatively, a medication called erythropoietin (EPO) can stimulate the production of red blood cells.

It is important to eat a diet that is high in iron. This is because iron helps red blood cells carry more oxygen. Foods that are high in iron include:

dark-green leafy vegetables
iron-fortified bread
beans
nuts
meat
apricots
prunes
raisins

Find out more about treatment for anaemia.

Bruising and bleeding

Chemotherapy can make you more vulnerable to excessive bleeding and bruising. This can cause:

easily bruised skin
nosebleeds
bleeding gums

Report any of these symptoms to your care team as you may need a blood transfusion to raise your platelet count.

You may need to take extra precautions to avoid damaging your skin and gums, including:

using an electric razor to shave
using a soft toothbrush
taking extra care when using knives or other sharp instruments
wearing a thick pair of gloves when gardening

Mucositis

In some cases, chemotherapy can cause pain and inflammation of the soft layer of tissue that lines the digestive system from the mouth to the anus (the mucous membrane). This is known as mucositis.

The severity of your symptoms usually depends on the strength of your medication. People having high-dose chemotherapy usually have more severe symptoms.

The symptoms of mucositis usually begin 7 to 10 days after you start chemotherapy.

If you develop mucositis, the inside of your mouth may feel sore, as if you have burnt it by eating very hot food. You will probably develop ulcers on the lining of your mouth and, in some cases, on your tongue or around your lips.

The ulcers can be very painful and make it difficult to eat, drink and talk. They may also bleed and become infected.

The symptoms of mucositis should clear up a few weeks after your chemotherapy finishes, although a number of medications are available to relieve the symptoms.

Loss of appetite

Some people who have chemotherapy lose their appetite and do not feel like eating or drinking. If you lose your appetite, it is still important to make an effort to eat healthily and drink plenty of liquids.

You may find eating smaller, more frequent meals better than eating three large meals a day. Try sipping drinks slowly through a straw rather than drinking them straight from a glass.

If you have serious problems eating and drinking due to symptoms such as mouth ulcers, you may need to be admitted to hospital and attached to a feeding tube.

You will probably be given a nasogastric tube. This is a tube that passes down your nose and into your stomach. The tube can be removed once you are able to eat and drink normally.

Skin and nails

Some chemotherapy medications can cause your skin to become dry and sore, particularly on your hands or feet. Your nails may become brittle and flakier than usual and white lines may develop across them.

During chemotherapy, and for some time after treatment has finished, your skin may become more sensitive to sunlight. Therefore, it is important to take extra precautions to protect your skin from the sun:

Avoid going out in the sun when it is at its hottest – this is usually between 10am and 2pm, although the sun can also damage skin before and after these times.
Use a sunscreen that blocks both ultraviolet A (UVA) and B (UVB) radiation and has a sun protection factor (SPF) of at least 15.
Dress to protect your skin from the sun – for example, wear a wide-brimmed hat to protect your face and scalp, and sunglasses to protect your eyes.

Memory and concentration

Some people who have chemotherapy have problems with their short-term memory, concentration and attention span. You may find that routine tasks take much longer than usual.

Exactly why these symptoms appear is unclear. They may be due to a combination of factors, such as fatigue and anxiety. However, the symptoms usually improve after your treatment has finished.

Sleep problems

Sleep problems are a common side effect of chemotherapy. They are thought to affect around half of all people being treated with chemotherapy.

Sleep problems can include difficulty falling asleep (insomnia), and waking up in the middle of the night and being unable to get back to sleep.

The following advice may help to improve your sleep:

go to bed only when you are sleepy
if you cannot sleep, leave the bedroom and only return when you feel sleepy
only use your bedroom for sleeping and having sex
avoid napping during the day, if this is not possible, try to limit your naps to about half an hour
avoid stimulants, such as caffeine, for at least six hours before you plan to go to bed

If this advice does not work, contact your care team. You may need additional treatment. A type of therapy called cognitive behavioural therapy (CBT) has proved to be effective in treating insomnia associated with chemotherapy.

Sexuality and fertility

Many people find that their interest in sex decreases during chemotherapy. However, this is usually temporary and your interest in sex should gradually return after your treatment has finished.

Some chemotherapy medications can stop women being able to conceive and can prevent men from producing healthy sperm. Loss of fertility is usually temporary, although in some cases a person can become permanently infertile.

If there is a risk that you could become permanently infertile, your care team will discuss the possibility with you before treatment begins.

A number of options are available. Women can have their eggs frozen to be used later in IVF (in-vitro fertilisation). Men can have a sample of their sperm frozen to be used at a later date for artificial insemination.

Diarrhoea and constipation

You may have diarrhoea or constipation a few days after you begin chemotherapy. Your care team can recommend suitable medication to help control the symptoms.

Find out more about treatment for diarrhoea and treatment for constipation.

Depression

Living with the effects of chemotherapy can be frustrating, stressful and traumatic. It is natural to feel ongoing anxiety and concern about whether your treatment will be successful.

Stress and anxiety can increase your risk of getting depression. You may be depressed if you have been feeling particularly down for two weeks or more and you no longer take pleasure in the things that you used to enjoy.

Contact your care team if you have psychological and emotional difficulties. They will be able to recommend treatments to help improve the symptoms of stress, anxiety and depression.

Joining a support group for people who are having chemotherapy may also help. Talking to other people in a similar situation can often reduce feelings of isolation and stress.

The charity Macmillan Cancer Support has an online directory of cancer information and support centres in England. You can search the directory to find a centre in your area. You can also call the Macmillan Support Line free on 0808 808 00 00.

Refusing or withdrawing treatment

In some circumstances, you may think that the benefits of chemotherapy are not worth the poor quality of life due to the side effects of treatment.

For example, if chemotherapy offered no hope of a cure and could only extend your life by a few months, you may feel that the extra few months are not worth undergoing treatment.

However, if you were looking forward to an event such as the birth of a grandchild or the wedding of a son or daughter, you may want to extend your life whatever the cost to your wellbeing.

There is no right answer or recommendation about when chemotherapy should be refused or withdrawn. Your care team can give you advice about the likely benefit of continuing with treatment, but the final decision will be yours.

This is obviously a very sensitive topic that you should discuss fully with your care team, family, friends and loved ones. You always have the right to refuse a particular treatment or to ask for the treatment to be stopped if you do not feel it is benefiting you.

Stopping chemotherapy does not mean that any symptoms you have will go untreated. Your care team will still provide support and pain relief. This type of care is known as palliative care.

If it's thought that you do not have long to live, it may be recommended that you are admitted to a hospice. Hospices provide care for people from the point at which their illness is diagnosed as terminal to the end of their life, however long that may be.