Managing Side Effects of Cancer Treatment

Transcript: Managing Side Effects of Cancer Treatment
July 16, 2003, 2:00 – 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net chat on managing side effects of cancer treatment, a live question-and-answer session hosted by Jamie H. Von Roenn, MD. During this hour, Dr. Von Roenn will answer as many questions as time permits. Some questions may be adapted so that Dr. Von Roenn’s answers can help as many people as possible.

Dr. Von Roenn will take questions from 2:00 – 3:00 ET. As you prepare your questions, please keep in mind that Dr. Von Roenn is unable to give individual medical advice in this setting. In answering questions about specific drugs, Dr. Von Roenn's comments will focus on the state of current research and clinical trials. This chat is governed by all terms and conditions of the Cancer.Net website.

Good afternoon and welcome. Thank you for joining us. Dr. Von Roenn will now begin taking questions.

Dr. Von Roenn is a medical oncologist and Professor of Medicine at the Feinberg School of Medicine, Northwestern University, and a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. She is Chair of ASCO's Education Committee and Editor of ASCO's Curriculum Series. In July 2002, she resumed the position of Medical Director of the Palliative Care and Home Hospice Program at Northwestern Memorial Hospital. Dr. Von Roenn served as the Program's first Medical Director, and helped establish Northwestern's inpatient hospice in the mid 1980s. She is Chair of the National Cancer Institute AIDS Malignancy Consortium, and previously served as Chair of the AIDS Clinical Trials Group Oncology Committee.

Dr. Von Roenn, thank you for taking the time to join us today.

Don2: How frequently do you observe cachexia with people with colorectal cancer? How do you manage it?

Dr. Von Roenn: The more advanced the disease, the more likely there is to be weight loss. In general, weight loss is not seen in colon cancer unless the disease is advanced. The first step in treatment for any patient with weight loss is to identify and treat symptoms that might interfere with eating, such as nausea, vomiting, abdominal pain, and depression.

Guest175: I've been getting constipated from my pain medication, and I don't know whether to try a new medication or deal with the side effects. What do you think?

Dr. Von Roenn: All of the opioid pain medications cause constipation, as the dose increases the constipation increases. I would be aggressive about treating the constipation with a softener and stimulant combination taken daily. The dose of the laxatives should be adjusted whenever the pain medication dose is adjusted.

JohnReinhardt: What can be done about nausea associated with chemotherapy?

Dr. Von Roenn: Now there are effective medications both for prevention of acute (early) nausea after chemotherapy and a newly approved drug for the treatment of delayed nausea. There are published guidelines for the prevention and treatment of chemotherapy-induced nausea and vomiting. There are now many therapeutic options available. So, if the first choice of drugs is ineffective, an alternate drug can be prescribed.

jenny:What are the side effects of radiation and the heart? I get a lot of people asking me about this because they are afraid of heart complications. Thanks.

Dr. Von Roenn: Radiation therapy to the heart depending on the radiation dose can cause accelerated coronary artery disease.

Guest256: My mouth is so dry after radiation treatment. What can be done?

Dr. Von Roenn: Dry mouth after radiation therapy is a common problem. Artificial saliva may be helpful. Additionally, oral balance, a gel that can be used in the mouth as well as on the lips, may improve the symptom.

Rverrill: My wife is suffering from deadening of her fingertips and toes as a result of her treatment for metastatic breast cancer (zoledronic acid, letrozole)—are there any treatments?

Dr. Von Roenn: The numbness in the fingers is more likely related to other medications that she has received. For example, vinorelbine or the taxanes are known to cause peripheral neuropathy, numbing and tingling in the fingertips. There are a variety of drugs that have been helpful to treat these symptoms, including anticonvulsants and antidepressants. Currently, the drug most widely used is gabapentin, which is effective across a wide dose range.

Guest24: What can be done about the fatigue resulting from chemotherapy and radiation treatments?

Dr. Von Roenn: If the chemotherapy and radiation therapy have resulted in anemia (hemoglobin less than 12 mg/dL), the anemia should be treated with an erythropoietic agent, which will result in improvement in the anemia and some improvement in the fatigue. Another drug that has been used to treat non-anemia-related fatigue is methylphenidate, though no randomized controlled studies have been completed. There is increasing evidence that exercise improves energy.

isafrance: Is a light sport like walking or swimming more of a benefit, or is it too much for my body?

Dr. Von Roenn: The more activity you are able to participate in the better. Muscle mass is very quickly lost with excessive rest and maintenance of muscle mass correlates with maintenance of strength and well-being.

Guest513: I think my husband is having male menopausal symptoms from his treatment. He thinks I am crazy. Is there such a thing? How can I help him find comfort?

Dr. Von Roenn: Men treated for prostate cancer experience hot flashes frequently. There are a variety of effective agents, including venlafaxine, gabapentin, and hormonal therapies.

Read more about menopausal symptoms in men.

Peggy: What do I do about difficulty swallowing and a terrible taste in my mouth that keeps me from eating a number of foods because they make the taste even worse?

Dr. Von Roenn: If it is a metallic taste, simple things like using plastic silverware often make a difference. Alternatively, trying a variety of spices may improve the pleasure from eating. Difficulty with swallowing results from a variety of problems. Depending on the cause, one would recommend different strategies. If there is difficulty getting the food down or a sense of getting full too fast, metoclopramide is an effective treatment.

If the problem is mouth sores or esophageal ulcers, then specific therapy for the ulcers is indicated. If the problem with swallowing is related to a burning sensation in the chest, then drugs which block acid production in the stomach would be the appropriate approach.

Lana: My friend has given me a fermented soybean protein drink that is supposed to be helpful in protecting the body from the adverse side effects of chemotherapy and radiation. Is there any harm in trying it?

Dr. Von Roenn: Depending what other supplements are part of the soybean protein drink, it is unlikely to be harmful. There is inadequate information about the interaction between chemotherapy and radiation and non-pharmacologic products. We do know that high doses of antioxidant vitamins may interfere with the effectiveness of chemotherapy.

TylersMom: My son is currently being fed through a nasogastric tube because his tummy is so upset that he won't eat. What can be done to help ease his upset tummy so he can maybe eat normally again?

Dr. Von Roenn: The correct recommendation depends on the cause of his upset stomach. If the cause is nausea and vomiting, this can be aggressively treated with combinations of drugs, generally with good relief. Metoclopramide is a drug which has antinausea effect in the brain and also stimulates the stomach to empty and move things through the digestive tract.

This is a drug that is likely to be of benefit in combination with other antinausea agents. This would also be useful if feeling full quickly when eating is part of his problem. If the problem is pain primarily, this can readily be controlled with standard pain medications. More than 90% of cancer-related pain can be readily, effectively managed.

isafrance: What kind of food can I eat to avoid strong diarrhea?

Dr. Von Roenn: The diet should be high-fiber and often low in lactose, as many patients, particularly older patients, may develop lactose intolerance, which in itself is associated with diarrhea. In addition, there are multiple effective antidiarrhea medications, including Lomotil (diphenoxylate and atropine ) and Imodium (loperamide), which can be taken around the clock.

If these are ineffective, tincture of opium is an exceedingly effective antidiarrhea agent that can be slowly increased until there is relief of symptoms. Octreotide is a drug that is effective for particular types of diarrhea. Read more about diarrhea.

Guest490: Is there anything that can be taken to help prevent or stop the loss of muscle mass? Would testosterone help?

Dr. Von Roenn: For men, adequate testosterone levels are essential to maintain muscle mass. There are, however, no safety data with above normal levels of testosterone. Oxandrolone is an oral anabolic agent that is currently being studied in patients with cancer-related weight loss. The early study shows an improvement in muscle mass with treatment, but results of the randomized placebo controlled study have not yet been published.

barb: Is it okay to drink green tea between chemotherapy treatments, or should it be avoided altogether?

Dr. Von Roenn: Green tea contains significant antioxidant activity, and depending on the amount of tea you drink, it may interfere with your chemotherapy.

Yanzi: My friend told me acupuncture works for pain. Can I try it?

Dr. Von Roenn: Acupuncture in the hands of an experienced therapist can be an effective, adjuvant therapy both for pain and nausea and vomiting. As long as your platelet count is adequate, and you have nothing which predisposes you to bleeding, it is reasonable to try acupuncture.

Peggy: I am on docetaxel and I am losing my fingernails. What should be done and by what type of physician?

Dr. Von Roenn: The loss of fingernails with docetaxel is a recognized side effect of the drug. It is occasionally associated with local infection, which should be treated with antibiotics if present.

Guest476: My mother seems to bruise easily. Is this serious, and what can be done to correct it?

Dr. Von Roenn: Depending on the severity of the symptom, such as pain, loss of function, etc., the dose of docetaxel may need to be changed. There are many causes of bruising. A low platelet count or a clotting abnormality from liver disease or blood thinners may account for the bruising. Chronic steroid use also causes thin skin and easy bruising. The seriousness of the problem is dependent on the cause.

sandy: I think I have depression. I probably had it before I got cancer, but I think it is worse now that I am in treatment. Is there anything that can be done while I am still getting treatment?

Dr. Von Roenn: Depression is unfortunately under-recognized and under-treated in the setting of cancer treatment. Many effective antidepressants that are well tolerated are available. Drug treatment in combination with counseling is likely to improve your depression as well as your overall sense of well-being.

Read more about depression.

Guest785: I prefer natural medicine for nausea and vomiting; what do you think?

Dr. Von Roenn: If the natural medicines are working for you, there is no reason not to use them. It is important to let your health-care providers know exactly what you are taking.

Yanzi: Is it okay to take immune system boosters during my chemotherapy?

Dr. Von Roenn: Yes, but it is important to let your health-care providers know what you are taking to avoid adverse interactions between the medications and the supplements.

CA: Over the last 10 years I have undergone chemotherapy for breast cancer three times. I am currently undergoing chemotherapy again. After the last two treatments, I was told that I am anemic and was given epoetin alfa. I have had trouble with energy level. Is there anything nutritionally, etc. that I can do to help with this? I am a vegetarian but eat eggs and fish.

Dr. Von Roenn: The goal should be a hemoglobin level of 12 mg/dL. For every increase in hemoglobin, there is improvement in energy. A widely used drug for fatigue is methylphenidate, even though placebo controlled trials have never been completed. Exercise appears to improve energy and maintain muscle mass, which improves strength.

Guest83: I'm tired most of the time. Is there something I can do or take to be less tired and out of breath?

Dr. Von Roenn: For fatigue, exercise helps, as does treatment of anemia. Shortness of breath can be due to the fatigue, the anemia, or underlying lung disease whether from cancer or not. Low doses of opioids are very effective for the treatment of shortness of breath, and can be initiated regardless of the underlying cause.

Read more about fatigue.

CA: I am also interested in alternative/complementary therapies but find it difficult to know who I can trust, and I don't want to do anything harmful. How do you find dependable sources for this information?

Dr. Von Roenn: The National Institutes of Health now has a National Center for Complementary and Alternative Therapies (http://nccam.nih.gov) and can serve as a resource for this information.

fromseattle: My 10-year-old daughter is going though radiation treatment. I am afraid that a side effect of her treatment may be infertility later in life. What can I do to protect her chances of having children of her own?

Dr. Von Roenn: The likelihood of infertility is related to what area of her body is being radiated. I am not aware of any preventive approaches in children, but I am not a pediatric oncologist. I would recommend that you discuss this specifically with the physician.

Smithy: My doctor has said I am at increased risk for infections. What can I do to protect myself?

Dr. Von Roenn: If you are at increased risk for infection because of a decreased white blood cell count, this is an expected side effect of chemotherapy and will resolve spontaneously. If your low blood counts are prolonged or you have previously experienced an infection secondary to your low blood cell count, then growth factors such as G-CSF would be effective to decrease the duration of your low count. Many people advise those with low blood counts to avoid being in crowds and eating unpeeled fresh fruits and vegetables.

Guest70: I am having trouble sleeping at night and a friend suggested melatonin. What are your thoughts?

Dr. Von Roenn:Melatonin may be effective for promoting sleep. There are a variety of behavioral interventions and sleep aides which are also effective.

Read more about sleeping problems.

JohnStevens:My wife is undergoing treatment for ovarian cancer and I can tell that she is in a lot of pain, even with the medication she has. I’m not sure the doctors realize how bad it is. Is there anything we can do?

Dr. Von Roenn: Yes, there are very effective therapies for the treatment of pain. It is important to tell the physician how bad the pain is and how it interferes with her function and quality of life. Both opioids and adjuvant therapies such as steroids and gabapentin (among many) can control pain effectively for more than 90% of patients with cancer-related pain. It is important that at every visit with the physician, the status of her symptom control be discussed.

Moderator: The chat is now ending. Thank you for your thoughtful questions. We hope this discussion has been valuable, and we regret not being able to answer every question. Dr. Von Roenn, thanks again for lending us your time and expertise.

TRANSCRIPTS: To receive a copy of this transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net on August 13, 2003, from 2:00 – 3:00 PM ET for a live chat about nutrition before, during, and after cancer treatment. The featured experts are David Alberts, MD, and Cynthia Thomson, PhD, RD, FADA. Dr. Alberts is Regents Professor of Medicine, Pharmacology, and Public Health, and Director, Cancer Prevention and Control at the Arizona Cancer Center. Dr. Thomson is Assistant Professor in Nutritional Sciences at the University of Arizona College of Public Health.

The chat room is now closed. Thanks again for joining us.