Coping with chemotherapy

UPDATE Clinical chemistanddruggist.co.uk/update-plus

Module 1799

August

Coping with chemotherapy

Clinical:

From this module you will learn:

●●The different drug classes involved in treating cancer ●●Some of the most common side effects experienced after cancer treatment and measures that can be taken to address them ●●Side effects that warrant immediate emergency referral

● Coping with chemotherapy

6 August*

● Recognising cancer: lung and prostate

13 August

● Recognising cancer: breast and ovarian Practice: ● Integrating new staff

*Online-only for Update Plus subscribers

20 August* 27 August

Asha Fowells MRPharmS

According to Macmillan Cancer Support almost 1,000 people in the UK are diagnosed with cancer every day. As if cancer is not scary enough, the condition is commonly linked to another dreaded C-word: chemotherapy. This article considers some of the problems patients may experience once they start their treatment, as well as those that linger once their therapy has come to an end. It is at this time that pharmacists can play a significant role as a consistent care provider, as a patient’s contact with specialist oncology services may vary considerably at different times.

Lowered immunity A significant side effect of chemotherapy that poses a serious threat to health is lowered immunity. This risk is highest during a chemotherapy treatment cycle, but it can persist after chemotherapy is completed. This frequently occurs in patients receiving treatment for leukaemia or myeloma, as their white blood cell counts will already have been reduced. Patients who have undergone chemotherapy can reduce the risk of infection by: following good personal hygiene; avoiding contact with people who have common illnesses such as influenza or stomach bugs; and making sure any cuts and grazes are cleaned and covered. During and after treatment, regular blood tests will also be conducted so a downward trend in immunity – ie a reduced white blood cell count – can be identified and managed. Patients undergoing cancer treatment should have been given details of a nominated healthcare professional to contact in an emergency. It does no harm for you or your staff to check that the patient has this information and encourage them to use this service. Maintaining awareness of the signs that warrant immediate attention (see Box 1: Referral points) can ensure timely patient care.

Low mood and energy Some patients’ energy levels are unaffected by chemotherapy, with some individuals even Chemist+Druggist 06.08.2016

Pharmacists may be the first medical professionals to spot complications arising from cancer treatment

feeling better than they did before treatment. However, the majority find cancer treatment draining and this feeling can persist long after treatment is complete.

Box 1: Referral points You should refer a patient to their nominated emergency healthcare professional if they display any of the following symptoms: ●● fever ●● flu-like symptoms ●● bleeding from mucous membranes ●● severe mouth ulcers ●● diarrhoea ●● persistent shivering ●● chest pain ●● persistent vomiting ●● breathing difficulties

While the instinct is to thoroughly rest under such circumstances, cancer-related fatigue may not be improved by rest in the same way as other conditions, for example post-viral fatigue. Instead, there are other recommendations you can make to help reduce fatigue: Pacing involves the patient taking advantage of times when they feel better – both physically and mentally – to plan ahead, so they can reduce the amount of arduous activities they need to do in the near future. For example, balancing activities that cannot be avoided (meal preparation, for instance) or are enjoyable (such as socialising with friends) with relaxation periods. These periods do not need to involve sleeping; listening to music, reading, meditation or simply spending time with others can be just as therapeutic.

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Outsourcing some chores can also help and need not be costly. Hiring a cleaner for a couple of hours each week or sending dirty clothes to a laundrette for a service wash, for example, can conserve a person’s energy for more interesting or enjoyable pursuits. Taking gentle exercise may seem counterintuitive, but you can recommend that even a short walk each day can help boost energy levels in the longer term. Keeping track of energy levels throughout the day, including the length and quality of the patient’s sleep periods and times they spend resting, is also a useful technique. You should recommend that patients pay particular attention to anything that increases or reduces tiredness. They can, for example, keep a diary of activities undertaken and record associated levels of fatigue. This may be useful for the oncologist when the patient has a check-up. Seeking help from other experts may also be valuable. For example, a pain management specialist will be able to help someone who is suffering from chronic pain understand their analgesic options and ease fatigue; a counsellor can help a patient struggling to come to terms with their diagnosis; while a dietitian, who will take into account factors such as whether the cancer or its treatment has affected the patient’s appetite, energy requirement or absorption of nutrients, can help a patient eat sensibly during their treatment. In the second example, a patient’s diet may be modified to include several small meals throughout the day and choosing nutritionally dense foods such as cheese and crackers, rather than chocolate and crisps. The impact of fatigue cannot be underestimated. It can have a profound effect on a patient’s relationships with friends and family, as well as affecting their work lives and triggering low moods. This in turn can lead to mental health issues, such as depression or anxiety. You and your staff should be alert for any sign that a mental health condition may

Advice on side effects, such as hair loss, can greatly improve a patient’s quality of life

be brewing (see C+D Update module: Diagnosing depression) and refer appropriately.

Changes to hair, skin and nails Cancer is inextricably linked to hair loss, as it is a side effect of many chemotherapy agents (see box below), but the skin and nails are often affected. Hair loss may start a week or so after the first dose of chemotherapy. However, it usually becomes noticeable after a month or two. It most commonly affects the scalp, but other parts of the body can be affected, including pubic and nasal hairs, eyelashes and eyebrows. This process can be very distressing, particularly if the patient is one of the minority who, after treatment, do not regain their hair, or finds that it has changed significantly in appearance and texture. Some practical advice

When is chemotherapy not chemotherapy? Cancer treatments tend to fall into one of three categories: surgery, radiotherapy or chemotherapy. But the term ‘chemotherapy’ is often used with regards to any medical treatment for cancer, which can be misleading. Chemotherapy drugs – also known as ‘cytotoxic’ drugs – attack rapidly dividing cells. While this is one of the main characteristics of cancer cells, fast growth is also a trait of many other cells in the body – such as those that form hair, skin, the stomach and blood. This explains some of the common side effects of these treatments. For example, hair loss, tiredness, skin complaints and vomiting. Biological treatments are sometimes also lumped under the term “chemo”, but they

exert their effect in a different way. These treatments tend to disrupt one or more processes in the body that enable cancer cells to grow and reproduce, such as: ●● interfering with the action of certain hormones involved in cell proliferation ●● blocking the growth of blood vessels ●● triggering the immune system to destroy cancer cells. A more accurate term for these treatments is ‘targeted therapies’. They are considerably more expensive than cytotoxic medicines and are only suitable for certain patients. It should be noted that they are not side effect-free, even though they are referred to as ‘targeted’.

you can offer these patients includes: ●●using gentle hair products ●●avoiding chemical treatments such as dyes and perms ●●avoiding the use of heated appliances, for example hair dryers and straighteners ●●not tying hair back tightly, such as in a ponytail. Wearing a soft cap or turban at night and sleeping on a pillow that is made of natural fibres can minimise mess, and wearing a hat or scarf during the day can protect the head from changes in environmental temperature. Patients may wish to cut their hair short before treatment so that the hair loss is less noticeable. Skin care should be managed in such a way as to reduce itching, prevent infection and provide protection. Simple tips include washing in warm (not hot) water and using gentle skin products that are alcohol and perfume-free. The oncology team will be able to provide specific recommendations, including whether certain products – for example antiperspirants – should be avoided. You can recommend simple sun protection measures, including using an SPF-containing sun lotion, loose clothing that covers the skin and wide brimmed hats. The chlorine used in most public pools can exacerbate sensitive skin, so it may be best to recommend patients avoid swimming. Nails may become brittle, ridged or discoloured as a result of chemotherapy. You should recommend that patients keep them clean and short, and use gloves for household cleaning and gardening to reduce the risk of cuts and subsequent infections. The frequent application of moisturiser can ease nail flaking. Discolouration can 06.08.2016 Chemist+Druggist


be masked using nail polish, however, you should know how a product is applied and removed before recommending as some can exacerbate brittleness.

hot water to reduce the risk of scalding. You can also recommend occupational therapy for patients struggling with everyday activities, such as walking or dressing.

Peripheral neuropathy

Sexual issues

Peripheral neuropathy – nerve damage that can impair sensation, movement and bodily functions – is a side effect of many of the medications used to treat cancer (see Box 2: Medical treatments that cause peripheral neuropathy). Symptoms can include tingling or prickling, pain, numbness and loss of balance. Any of these can make everyday tasks difficult. However, this problem can persist for months or years after treatment, and may in some cases be permanent.

The effects of cancer treatment on fertility is discussed with patients at their initial consultations – ovary function may be temporarily or permanently affected, as can sperm numbers and motility. More generally, libido may be reduced, partly as a result of lowered energy levels, but also as a result of treatment. Women may experience pain during sex; itching, burning, dryness, atrophy, infections or a narrowing of the vagina; and

Box 2: Medical treatments that cause peripheral neuropathy ●● platinum-based drugs such as cisplatin ●● vinca alkaloids ●● taxanes ●● antimetabolites (eg methotrexate and fludarabine) ●● ifosfamide ●● etoposide ●● thiotepa ●● procarbazine ●● some biological therapies.

There are various management options for peripheral neuropathy, ranging from pharmacological interventions such as analgesics, antidepressants and antiepileptics, to complementary therapies such as massage, reflexology and acupuncture. You should make patients aware of the side effects of all of these treatments, which may occur in addition to those of their chemotherapy. Simple self-help measures you can suggest include: keeping extremities warm; wearing well-fitting shoes; doing gentle exercise; taking precautions such as using oven gloves; asking others for help with nail cutting; and avoiding

For more information There is some information on chemotherapy side effects on the NHS Choices website, which is a good resource for patients and carers: tinyurl.com/chemocoping5. Other useful resources for patients and healthcare professionals alike are the websites hosted by the charities Macmillan Cancer Care and Cancer Research UK, found respectively at: bit.ly/chemocoping6 and tinyurl.com/chemocoping7. The National Cancer Institute is based in the US, but gives a good overview of cancer treatments, including the difference between chemotherapy and targeted therapies: tinyurl.com/chemocoping8.

Chemist+Druggist 06.08.2016

menopausal symptoms, such as hot flushes and mood swings. Questions you and your staff should be prepared for include whether sex is appropriate – usually the answer is yes, but checking with the oncology team is recommended – and whether contraceptive measures need to be changed. Pregnancy must be avoided during treatment and – depending on the therapy – for some time afterwards. A barrier method of contraception may be advisable, because semen and vaginal secretions may contain traces of chemotherapy agents. This is another area where a pharmacist’s advice can improve a chemotherapy patient’s quality of life.

Take the 5-minute test 1. More than 1,600 people in the UK are diagnosed with cancer every day. True or false? 2. Chemotherapy drugs exert their effect by attacking rapidly dividing cells. True or false? 3. Biological treatments disrupt the processes in the body that enable cancer cells to grow and reproduce. True or false? 4. Unlike chemotherapy drugs, biological treatments are usually free of side effects. True or false? 5. One of the most significant side effects of chemotherapy is lowered immunity. True or false?

6. Cancer patients with symptoms such as fever, flu-like symptoms, severe mouth ulcers, diarrhoea or vomiting should be referred. True or false? 7. Chemotherapy only causes hair loss on the scalp. True or false? 8. Chemotherapy can cause nails to become brittle, ridged or discoloured. True or false? 9. Peripheral neuropathy caused by chemotherapy does not persist after treatment is finished. True or false? 10. Drugs that can cause peripheral neuropathy include cisplatin, vinca alkaloids and methotrexate. True or false?

Coping with chemotherapy CPD Reflect How do chemotherapy drugs and biological treatments differ? What can cancer patients do to help reduce fatigue and boost mood? Which medical treatments can cause peripheral neuropathy?

Find out more about targeted therapies from the National Cancer Institute website at tinyurl.com/chemocoping2

Plan This article includes information about

Read more about hair loss following chemotherapy on the Cancer Research website at tinyurl.com/chemocoping3

the difference between drug classes often referred to as chemotherapy, common side effects experienced after cancer treatment and measures that can be taken to address them. Symptoms that warrant immediate emergency referral are also discussed.

Act Find out more about chemotherapy’’ side effects, including tiredness, fertility and mouth problems, from the Macmillan Cancer Support website at bit.ly/chemocoping1

Read more about skin care during cancer treatment on the Cancer Research website at tinyurl.com/chemocoping4

Evaluate Are you now confident in your knowledge of the side effects of chemotherapy? Could you give advice to patients about lifestyle measures they can take to reduce these unpleasant effects?