Common Side Effects Seen in Cancer Treatment
The presence of side effects from chemotherapy, targeted and immunotherapies should be expected to occur, at some point, during cancer treatment. Being able to reduce their impact and hopefully maintain initially, and ultimately restore functionality offers a focus and goal toward recovery and a continued quality of life. This article will present common ill effects from therapy and offer solutions from multiple paradigms for their reduction. Having options implies that there is no one magic approach to reducing these symptoms and being open to try whatever is needed to feel better is an important attitude to cultivate.
Alopecia (Cancer induced alopecia, or CIA)
This is a distressing symptom from a cosmetic physical appearance change as well as an individual’s inner and outer self image. Loss of hair can include the scalp, the eyelashes, eyebrows and beard. In fact, fifty percent consider it the worst symptom of their treatment! The hair follicles are extremely sensitive to therapies designed to stop cancer growth. And because at any given time ninety percent are in an active growth phase, cancer therapies hone in on rapidly growing cells including hair follicles.
Hair loss can occur from any of the multiple cancer treatments, chemotherapy, immunotherapy and targeted therapies, or from radiation to the head. Statistics suggest hair loss in patients occurs in 80% with paclitaxel, 60-100% treated with doxorubicin, 60% with cyclophosphamide and 10-50%with 5 FU and Lecovorone.
Often a significant amount is lost in the early period of chemotherapy initiation. During treatment sixty -five percent of patients experience thinning or loss and the following hair guidelines are useful to protect follicles from greater damage. Use mild organic shampoos, less frequently than usual, with gentle drying and soft brushing. Avoid trimming and the heat of a hair dryer. Some people choose to buzz the scalp but if shaving is preferred, always use an electric razor. A wig or scarf may also be the desirable option, but with hair loss, always wear sunscreen or a hat outside.
The variables that determine regrowth depend upon the treatment, doses given, frequency of treatments, and the length of time, all of which affect the regrowth process. Expect a few months post-therapy for growth to begin, and hair will often change, often being thin or fine with changes in your normal texture, color, and amount of growth. Permanent loss is considered to have occurred if there is no growth after 6 months.
Treatments
Scalp Cooling
It has been shown to be useful to reduce chemotherapy-induced alopecia. There are options available, including gel packs or FDA approved electronic cooled caps that can be rented. The caps offer a pump that circulates a cooling gel at a controlled temperature. The mechanism reduces blood flow to the scalp, preventing less chemotherapy circulating to the head and slows the rate of metabolic activity in the follicles. The pump is started prior to an infusion, continues throughout and a short while after completion. The success rate is 50-70%.
Vitamin D
The epidermal cells of the skin, hair and nails produce Vitamin D in the fibrous protein keratin found there. Topical application of this active hormone form of Vitamin D produced by the kidney is being used with success. It can cause irritation to the scalp but a study of 23 breast and gynecologic cancer patients on taxane, with hair loss, showed a 50% reduction in alopecia.
Bimatoprost
This is a drug, in drop form, that is used in glaucoma to reduce intraocular pressure. Another noted effect with use was that it increased the length of the eyelashes. Studies were done on both Japanese and Caucasian women on chemotherapy, with eyelash reduction, and proved effective in lengthening, thickening and darkening eyelashes after 4 months of treatment. It can cause eye irritation which reverses when the drug is stopped,
Platelet Rich Plasma, PRP
This procedure involves separating whole blood and using the enriched plasma, containing growth factors, that is injected in the scalp. It is an out of pocket expense with inconclusive research to support this use but it has had success with hair regrowth.
Multi Vitamins and minerals
Supplement replacement in safe recommended dosages, along with adequate protein are important to support repair and healing. There are no clinical studies of chemotherapy induced alopecia, but these are essential nutrients in often depleted people that seem logical to take.
DHA
Studies suggest that the omega 3 fatty acid, docosahexaenoic acid, can protect against CIA by reducing oxidative stress on regenerating hair follicles as demonstrated in animal models.
N-Acetyl Cysteine
In animal studies, NAC protected against CIA during treatment with a combination of cyclophosphamide and doxorubicin. There there has been no clinical double-blind studies.
Low Level Laser Therapy
Has been shown to stimulate hair growth in mice subjected to CIA, and in controlled human studies. LLLT was studied as a means to stimulate hair growth as it affected epidermal stem cells activation. Within recommended guidelines it is considered safe, but the optimum determination of wavelength, coherence and dosimetrics needs refinement for hair loss treatment after cancer therapies.
Chinese Medicine
CIA is considered Yin deficiency and/ or blood deficiency from the Chinese Medicine perspective
Yin is considered the structural components within the body while blood is derived from Yin.
Blood provides nourishment to the body by its flow, inside the blood vessels and acupuncture channels and outside the vessels in the form of body fluids that moisten tissues and joints.
There are modified versions of classic, 2000 year herbal formulas, that are used for CIA.
For blood, Si Wu Tang Jia Jian, and for Yin Deficient CIA to support the Yin of the Liver and Kidneys, Liu Wei Di Huang Wan Jia Jian. While these are fixed recipes Jia Jian means the base formulas with additions and subtractions and the formulas are modified with herbs needed to specifically help hair loss.
Cancer Associated Anemia (CRA)
In patients receiving chemotherapies or radiation the presence of anemia or low red blood cell count is seen in approximately 50% of people. A lowered number of red blood cells reduces the body’s ability to extract oxygen from the lungs and transport it throughout the body to organs, tissues and cells.
Symptoms that can occur are tiredness and fatigue, palpitations, ple or sallow skin coloration, dizziness, poor appetite, cognitive slowing and irritability and anemia also reduces the sensitivity to chemotherapy and radiation.
The development and severity of symptoms are affected by how low the hemoglobin level is, and how rapidly it occurred.
Cancer associated Anemias are multifactorial in nature and categorized by either a reduced number of red blood cells being made or by excessive amounts being lost.
The multiple causes include:
Suppression of bone marrow production directly from the therapy
Invasion by the cancer into the marrow reducing red cell production
Blood loss from surgery
Invasion into tissues by the cancer cells causing damage and blood loss
Nutritional deficiencies such as iron, folate or B12, and iron, often associated with nutritional depletion or consumption from the body’s treatment of inflammation.
Autoimmune breakdown of red blood cells called hemolytic anemia, which can be caused by chronic lymphocytic leukemia
Frequent blood draws for lab testing
Radiation
Chronic kidney failure
Treatments
Iron/B12/Folate
These supplements have a place in treating anemia only if measurements in the blood indicate they are deficient. Otherwise there are potential ill effects that can occur. These levels are easily measured. Treatment for B12 and folate can be oral supplementation but iron orally is poorly absorbed and if indicated in CRA it is commonly given by IV infusion
Erythropoietin Stimulating Agent
Natural erythropoietin is a hormone made in the kidney. Low levels of oxygen in the body are sensed and this hormone is released and messages the bone marrow to produce more red blood cells. In CIA, a synthetically produced form can be given to correct cancer induced anemia. There is concern that erythropoietin has other effects that may produce anti apoptotic responses to cancer cells or stimulate tumor growth in some cancers making it important for patients to discuss its use with their oncologist.
Chinese Medicine Treatment of Anemias
The source of Blood in Chinese medicine is based on the combination of the production of the Qi energy, from digestion interacting with essence or your stored vital substance needed for growth and development. These are supported with traditional acupuncture, primarily the organ points located lateral to the spine used in conjunction with herbal formulas.
There are multiple supportive herbal chinese formulas which are prescribed based on symptom patterns, pulse diagnosis and body palpation. Those for digestion most commonly are a complex combination with ginseng being the principle herb, while the essence formulas are represented by kidney tonics. There are also herbal formulas to restore the white blood cells and platelets.
While there are no double blind studies of these treatments, this approach to anemia in Chinese medicine has been used in Chinese medicine herbal cancer clinics for many decades with success.
Anorexia or Loss of Appetite
Cachexia
In people undergoing cancer treatment, almost half experience loss of appetite called anorexia; along with cachexia, which is the breakdown and loss of skeletal muscle mass, with muscle wasting and associated weight loss. It is often also accompanied by loss of fat mass too. It is a serious problem, and considered responsible for 30% of cancer deaths. It is resistant to treatment, using nutritional resources and appropriate dietary intake.
The problem is complex and made more difficult in that both the cancer itself and its treatment both create different effects. Aspects of cachexia and muscle wasting involve cancer’s ability to maintain its replication and continued growth by regulating and controlling cellular signaling, vascular enhancement and immune regulation, within the host, to enhance its own survival.
Effects:
Cachexia is insidious and can slowly develop early in treatment, but often occurs later with progression of disease. Treatment factors influencing it include:
The underlying inherent strength and overall level of heath of a person offers a level of protection
Chemotherapy treatment causes nausea,vomiting and diarrhea, reducing food and fluid intake and calorie absorption; examples being 5-FU, cisplatin and Irinotecan.
Chemotherapy suppresses appetite, examples being platins and cyclophosphamide
Inflammation from chemotherapy alters mitochondrial action, via cytokine activation of oxidative stress, and shifts it away from energy production. As a result muscle energy and strength is reduced, exemplified by the potential effect of diminished cardiac muscle function and potential heart failure associated with the drugs herceptin and doxorubicin.
Loss of muscle mass and strength, reduces physical activity,a known way to improve muscle mass.
Specific cancers, the colon and stomach, pancreas and lung cause greater loss of muscle mass and muscle wasting.
There are neuroendocrine interactions that decrease appetite and desire for food. This can be associated with treatment impairment of taste and smell and importantly can also be a stress response with anxiety to the disease itself.
Manipulation of neuroendocrine functions occurs that also create metabolic imbalances in the hypothalamic-pituitary-adrenal axis prompting the release of glucocorticoids that drive tissue breakdown, and intestinal Vagus nerve dysfunction can affect bowel motility and digestion.
Metabolic alterations shift the body from promotion of building and repair to breaking down tissues, resulting in shifts of pathways that promote protein breakdown. In skeletal muscle this action affords the cancer materials such as glucose, glutamine and ketones that can be utilized for energy production and results in atrophy, or loss of muscle mass and decreased strength.
Activation by the immune system of signaling via small proteins, cytokines, that promote inflammation and tissue damage from oxidative stress both of which can be generated by both the body and cancer cells. This process can promote signalling for programmed death of skeletal muscle cells.
Cancer cell growth and spread involves signalling pathways that promote cachexia.
The microbiome can contribute to cachexia via gut inflammation and immune reactions from barrier disruption.
Also, there is the intestinal production of ghrelin which activates appetite through the hypothalamus,which in cancer patients has diminished effect.
These changes in appetite leading to weight loss, diminished appetite and muscle wasting alters the person’s appearance often affecting the family dynamic. Meal time has meaning in many cultures as a time to cook, eat and interact together and is the expression of love in the family. Also, when someone becomes cachectic, thin and muscle wasted a caregiver can feel that they are not providing the necessary care their loved one deserves.