Side effects

 

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Side effects from treatment

Side effects are very difficult to predict. Not only is every patient different, but the side effects are largely dependent upon what chemotherapy is being used. 

If you know what regimen you are going to have you can look up the side effects of each drug or the whole protocol at the three links below.

BC Cancer agency patient information sheets

BC Cancer Agency professional cancer drug monographs

BC Cancer Agency chemotherapy protocols

Check out our "Support Drugs" page to read more information about what drugs are used to manage side effects.

There are some chemotherapy regimen's which come with nearly no side effects. Rituxan is a good example of this. Further information about Rituxan side effects is at the bottom of this page.

CHOP is one of the most common chemotherapy regimens used for NHL. It is considered a medium strength combo, and comes with mild to moderate side effects for most people, and severe side effects for some. 

In medical studies side effects are assigned a grade to indicate their severity. Grade 1 are the mildest level of toxicity, and Grade 4 the most severe. Here is link to the World Health Organization definition of what the grade means for each type of side effect. This link should open the PDF document to page 71. if not then see page 71 for the start of the definitions.

World Health Organization definition of toxicity grades

 

Nausea and vomiting

Let's start off with the nausea and vomiting thing. For the most part that should not be a problem no matter what regimen you are on. The drugs Ondansetron and Granisetron (brand names Zofran and Kytril) are so effective that even with the most powerful chemotherapy most patients experience no vomiting at all. Ondansetron is the more common choice, but Granisetron is also very common. Both drugs are very expensive, but even if you must pay for your own drugs you will not regret the expense. There are other drugs which help as well, but those are the two most potent ones.

Personal note from the webmaster: I didn't take either for my first CHOP chemotherapy and to say that I barfed my guts out was an understatement. I took it every time after that and never so much as had a tummy ache.

There are also several newer anti-nausea drugs which can be used in conjunction with Ondansetron or Granisetron when even stronger anti-nausea measures are needed. They are Dolasetron and Palonesetron. More information about all these drugs is on our Support drugs page. Just click on that menu item on the left.

 

Mouth sores and changed taste

Mouth sores are not too common with regular chemotherapy but they are very common during Stem Cell Transplants. They are caused by the damage to the mucous membranes of the mouth and throat, and they can be extremely painful. Often morphine is required during an SCT to control the pain.

The first step in avoiding them is to practice good oral hygiene using a mouthwash of baking soda and water. Swish 3 or 4 times a day with that. When brushing be sure to use a soft bristle toothbrush.

One of the most common treatments is an over the counter remedy called Magic Mouthwash. It is something your pharmacist can make up for you as follows:

Magic Mouthwash recipe

Viscous Lidocaine (1 part)
Maalox (1 part)
Benadryl (1 part)

Swish and spit 5 ml no more often than every 4 hours. It will help ease the pain and prevent further mouth sores from developing. Nothing but time will totally heal them, but they will heal eventually.

Another preventative measure is an anti-fungal mouthwash of Nystatin. It prevents fungus and yeast infections. Typically you swish and swallow it since it is not absorbed through the stomach or skin.

Taste changes are harder to control. Many people find that meat in particular becomes unpalatable and tastes like ash, or metal. Others find that food in general just has no taste and they lose the enjoyment they had in eating. This as with most side effects is temporary but it can be very disheartening. It is important to keep up proper nutritional intake during chemotherapy so if your taste is changed to the point where you can no longer eat properly you should be sure to supplement your diet with a proper daily vitamin, or supplemental nutritional meal replacement shakes and drinks.

 

Fatigue

This is one you will probably experience with most chemotherapy and many radiation treatments. It is often the most bothersome side effect because it can last a long time.  It is usually more severe with age, and poor physical fitness, but even being young and fit is no guarantee you will avoid it. One of the keys to managing fatigue is to keep active even when you feel too tired. Fatigue feeds on itself, so keeping active helps keep it under control. Just don't overdo anything. If all you can manage is a walk to the end of the street and back, then that's OK.  For the majority of patients fatigue does go away after treatment stops. Your local Cancer Society or Cancer Centre can provide you with information about how to deal with and combat fatigue.

 

Hair loss

Yes this probably the most dreaded side effect. For some reason we humans are very attached to our hair and get quite emotional when it is involuntarily taken away from us. Even knowing it will grow back doesn't soothe the soul very much.  The good news is that when it does grow back most people find they have more of it, it is darker, and it is usually curly for about the first 9-12 months after it grows in.

One aspect of hair loss that is seldom mentioned is that it usually affects the whole body. Arms, legs, chest and beards for men, and well, other areas too. Even those pesky nose hairs are likely to go away. Eyebrows and eyelashes seem to be about 50/50 chance.  
Whether or not you lose your hair really does depend on the therapy. Rather than trying to list all the drugs that cause hair loss, we have listed just a few that are UNlikely to cause hair loss:

Rituxan, Zevalin, Bexxar, - No chance of hair loss

CVP - Little chance but some hair thining likely

Fludarabine - Very little chance of hair loss

Chlorambucil - Very little chance of hair loss

 

Peripheral Neuropathy

This means numbness or tingling in the extremities. This is caused by damage to the nerve endings. Mostly the fingers and toes. This side effect is very particular to certain drugs. Mostly Vincristine and related drugs. With Vincristine PN is very common but it also usually goes away within weeks or months of stopping therapy. When it gets to the point that the patient is dropping things, and can't do simple tasks like buttoning a shirt, then the doctor should reduce or eliminate the dose.

 

Neutropenia, Thrombocytopenia, and Anaemia

Neutropenia means a lack of the specific white blood cells called Neutrophils. Those are responsible for fighting infections. Thrombocytopenia is the lack of platelets, which are responsible for blood clotting and prevention of bleeding. Anaemia is the lack of red blood cells which deliver oxygen to the body's cells, and therefore a lack of it results in fatigue.

Of the three Neutropenia is the one that is virtually guaranteed for anyone undergoing treatment. All the NHL treatments are geared towards killing white blood cells. What is important is the level of neutropenia. If it becomes severe then any infection no matter how small, can become life threatening. During standard chemotherapy this is not all that common but the risk can't be ignored. Some cancer centres will administer Neupogen during chemotherapy, although that is not considered standard practice.  During an SCT, then Neupogen is considered a "required" therapy. Neupogen is a neutrophil growth factor which stimulates your body to produce them very rapidly.

Thrombocytopenia and Anaemia are less common. Thrombocytopenia is harder to deal with, without using platelet transfusions. Anaemia can be dealt with either with blood transfusions or with red blood cell growth factors like procrit and aranesp. See the "Support Drugs" page for more information on those.

 

Rituxan side effects

Here we will discuss Rituxan side effects separately from chemotherapy. The notes here are likely to apply to other monoclonal antibody therapies as well since they have much in common with Rituxan.

Rituxan deserves it's own section on side effects because it is not a chemotherapy. It is a monoclonal antibody which targets only Lymphocytes (normal or cancerous) with the CD20 marker on their surface. Therefore it does not damage any other cells so side effects are rare. Nonetheless it is a foreign substance that is being put in your body, and sometimes your own immune system can react to that invasion in unusual ways.

During the first infusion of Rituxan is when most patients will experience some reactions. They will start the drip off very slowly to avoid most of them. These reactions include fever or chills, rigors (shivering uncontrollably), swelling of the mouth or throat, headache or body ache, hypotension (low blood pressure), itching, dizziness and maybe nausea. All patients will be premedicated with Tylenol and Benadryl to minimize these reactions.  It is extremely important for the patient to notify the nurse the instant he/she notices any of these reactions so they can stop the drip and give further medication.

Almost every patient will experience some of those reactions but not all of them. Fevers, chills, rigors and other "allergic type" reactions are most common. There are many other very rare infusion reactions most of which are not serious. Click here to go to the full Rituxan "Adverse Events" web page to read about them.

Once the reactions start, they will stop the drip, give more medication wait a few minutes then start the drip again.  If those reactions are very strong they may also give Demerol and/or steroids when they stop the drip. Once the drip is started again they will increase the rate about every 30 minutes if there are no further reactions.

After that first infusion it is rare to experience any further reactions during the infusion.  However if they do occur they will be treated exactly the same as during the first infusion. 

 

Later side effects

These are even more rare. Nevertheless some patients do experience additional side effects unrelated to the actual infusion.

The following anecdotal events have been reported by patients following Rituxan therapy. These events were in response to the question, "What unusual side effects have you noticed after Rituxan therapy as opposed to infusion related side effects?"

Remember, these are patient reports and not scientifically verified side effects.

  • Body aches and pains lasting many hours after each infusion was done.
  • My doctor suggested Rituxan therapy may preclude vaccine treatment until the B-cell population has had a chance to recover. That can take 6-9 months as per Rituxan's own documentation.
  • Ongoing allergic type of side effects, runny nose, sneezing, rashes, itching etc.
  • Possible itching peeling and blistering of skin on the hands and feet
  • Tightness in chest and raspy throat
  • Stuffiness or runny nose for days or weeks after the infusion
  • Other minor lung irritations
  • Some of the above resolved by Benadryl or Steroids like Prednisone.
  • Folliculitis of the scalp. (Inflammation of the hair follicules)

 

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