Managing Side Effects of Cancer Treatment Chat Transcript with Michael C. Perry, MD, FACP
Monday, July 25, 2005, 2:00 – 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Managing Side Effects of Cancer Treatment, a live question-and-answer session hosted by Michael C. Perry, MD, FACP.

During this hour, Dr. Perry will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

Some questions may be adapted so that Dr. Perry's answers can help as many people as possible.

Dr. Perry will take questions from 2:00 – 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Perry is unable to give individual medical advice in this setting, nor is he able to address questions that include information specific to one person's medical profile.

The information presented here is for informational and educational purposes only and is not intended to substitute the professional medical advice or treatment recommendations provided by your doctor.

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

Michael C. Perry, MD, FACP, is currently the Director of the Division of Hematology and Medical Oncology and Associate Director for Cancer Research at the University of Missouri Ellis Fischel Cancer Center.

Dr. Perry's research interests include breast and lung cancers, and he has published more than 140 articles in numerous journals.

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

andrea: Could you please discuss peripheral neuropathy from paclitaxel (Taxol)? Also, is there any indication that taking glutamine (a supplement that helps minimize loss of muscle mass while improving protein metabolism) after the completion of paclitaxel treatment helps neuropathy?

Dr. Perry: Peripheral neuropathy is one of the most disabling symptoms and appears to be dose-related. That is, the more doses you get, the more peripheral neuropathy the patient experiences. There are new medicines under evaluation to stop this from occurring, but they are not yet commercially available. There have been reports of several things to improve this, but none of them have panned out in the long run.

Guest143: I was just diagnosed with breast cancer and am also a diabetic. I would like to know if I should be concerned with the possibility of chemotherapy affecting my blood sugar.

Dr. Perry: Chemotherapy may affect blood sugar levels in someone with diabetes, but more importantly, the dexamethasone (Decadron) used to prevent nausea and vomiting will almost certainly increase the patient's blood sugar level for several days surrounding treatment. The doctor who manages your diabetes should be aware of this and may want you to take additional medication around this period of time. Certainly, you will want to do increased monitoring of your blood sugar levels to make sure they do not get out of control.

Vickie: I am currently undergoing chemotherapy for breast cancer and have had two of my four paclitaxel (Taxol) treatments. Are muscle cramps/aches and joint pain all over my body typical side effects, and what can be done to alleviate or ease them?

Dr. Perry: About 40% of patients who receive paclitaxel experience aching in the muscles or joints after treatment. Some patients get relief from simple things like acetaminophen (for example, Tylenol), but others need stronger medications, even narcotics. This typically last only three to four days. Once you've been identified as a patient who gets this symptom, you can start taking pain medicines in advance to make the next episode easier.

Guest503: How long after starting chemotherapy will I lose my hair?

Dr. Perry: Most patients who receive chemotherapy will experience thinning of the hair about three weeks after the start of chemotherapy. I tell patients to use that time to select a wig that matches their own hair color, style, etc., so that they have it available when their own hair starts to fall out.

Once the hair starts to fall out, it's reasonable to have the head shaved so as not to have your hair falling out on your pillow every night.

When hair regrows after chemotherapy, it is sometimes gray and curlier than before. Some people like this effect.

Guest128: What are the best ways to cope with nausea and constipation side effects of chemotherapy?

Dr. Perry: The best ways to cope with nausea and constipation are to prevent them. If you wait until you are already sick, it's difficult to get ahead of the symptoms. Oncologists divide chemotherapy drugs into several categories depending on how likely they are to cause nausea and vomiting.

Then they pick a program of antinausea medicines, often in combination, to try and head off any nausea and vomiting. We usually give patients intravenous (IV) and oral medications at the time of chemotherapy and send them home with prescriptions to take on an as-needed basis. Interestingly, one major class of antinausea medicines can cause constipation. So, patients may need to take a laxative as well. Constipation is an unusual side effect of chemotherapy alone and is far more likely to be caused by narcotic pain medications. In our practice, when we start someone on a narcotic, we also start him or her on a bowel program. This could be something simple like prune juice, Milk of Magnesia, a stool softener, or multiple laxatives a day.

Carl: Can you please talk about depression and anger, especially how to deal with them so that you do not upset loved ones?

Dr. Perry: It is common to be angry when one receives a diagnosis of cancer and subsequently to be depressed. Because these feelings are natural, it does not imply that you are mentally ill. The secret to coping with these symptoms is to first recognize that they are there and discuss the situation with your doctor.

Medication may help the depression, as may counseling. Anger can often be handled best by taking up a physical activity. Playing racquetball always seemed like a good idea to me.

I had one patient write cancer on the racquetball, so every time he hit it, he was dealing his cancer a blow.

You should also let your family and friends know what you're feeling, so that they are not surprised by your reactions and can help you in the coping mechanism.

Guest107: My taste has changed after chemotherapy. Why, and what can be done to help it come back to normal?

Dr. Perry: We don't understand why patients' tastes change with chemotherapy, but many patients report they no longer like the smell or taste of red meat. I suggest they try other sources of protein, such as eggs, cheese, beans, etc. Also, I suggest they try food they previously didn't like, as some people acquire new tastes.

Some patients improve with a little additional zinc, which they can get from a multivitamin. Multivitamins are probably a good idea if your appetite is off; however, I don't encourage mega doses of vitamins.

BethS: My son has been taking temozolomide (Temodar) for eight sessions now and has increasing fatigue. How common is this?

Dr. Perry: Fatigue is common after cancer chemotherapy and sometimes is reversible, so it's worthwhile to look into potentially reversible causes, like anemia, which can be helped by erythropoietin. There are many usual medical causes of fatigue in the person with cancer, including thyroid problems, heart and lung problems, and poorly controlled diabetes.

Your primary care doctor and oncologist may want to look at your liver and kidney function, hemoglobin, blood sugar, etc.

Carol: My mom is in treatment for lung cancer. I've asked her if she is in pain and she says no. The problem is that I think she is in pain and trying not to let it show. What are some of the nonverbal clues she may exhibit to indicate she has pain?

Dr. Perry: It's very difficult to tell whether someone is in pain and how much pain they have because we don't have an instrument, like a thermometer, that we can uniformly use. Facial expressions may give a clue and reluctance to move in certain ways may also indicate that she is uncomfortable.

A frank discussion with her doctor may help uncover whether she is having pain, and if so, why she is reluctant to take medication.

Many patients interpret pain as a sign of weakness, or are afraid to take pain medication for fear of becoming addicted, or from a fear that the medication would not work later on when they would really need it.

We try to get patients to grade their pain on a scale of one to 10 and try and give them enough pain medication to get their scores down to zero or one throughout the day and night.

It's particularly important to get a patient's pain under control, so he or she can get a good night's sleep.

ny2cal: I would like to know how to deal with side effects of radiation therapy on the esophagus, particularly when the patient (my father) has serious difficulties eating and drinking, even water.

Dr. Perry: Cancer of the esophagus represents a difficult problem even without radiation therapy in terms of nutrition because of the frequent difficulty in swallowing. Many patients require narcotic pain relievers, and the patient's doctor should always be aware of the possibility of the superimposed fungal or viral infection. It is common for patients to require a peg tube to be placed directly into their stomach for supplement food and water. This helps maintain their nutrition when they are receiving radiation therapy.

Moderator: Transcripts of today's chat will be available July 26, 2005, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Guest585: What should be done about cisplatin (Platinol)-induced tinnitus that occurs two years after treatment for bone cancer?

Dr. Perry: This is a rare complication of cisplatin chemotherapy, and the patient should see an otolaryngologist (ear, nose, and throat doctor) to make sure there are not other causes of this problem.

spring: I have breast cancer, and I am taking exemestane (Aromasin). I recently had a bone density scan, and it showed soft bones. Would this be a side effect of the exemestane, and what is "soft bone" exactly?

Dr. Perry: Exemestane and similar drugs may slightly worsen osteoporosis (softening of the bones). The latest information suggests that periodic administration of a bisphosphonate may help prevent or reverse this side effect.

Guest6: I am being treated with steroids, and I have gained about 10 to 12 pounds. Is this normal? Is there a way to keep my weight down?

Dr. Perry: Most patients treated with steroids will gain weight. Some of this is fluid retention and goes away fairly quickly when the steroids are discontinued.

Some of it is actual fat seen in a round face and trunkal obesity with relatively thin arms and legs. Once you're off the steroids a calorie-controlled diet and exercise can reverse these effects.

Because a common side effect of steroids is a great increase in appetite, it's difficult to maintain your weight when you're on the medication.

Once off, then you can attempt to get back to normal baseline.

Neil: My husband had chemotherapy and radiation therapy to the head and neck and lost his saliva glands. They do not produce any fluids for him at all. What can my husband do to help his dry mouth?

Dr. Perry: A medication called pilocarpine (Salagen) may help to increase the flow of saliva. Some people must resort to carrying around a bottle of an artificial saliva solution to irrigate their mouth frequently.

Good dental care is key when the salivary glands have been irradiated, as without saliva the teeth can quickly deteriorate.

guest8: My wife has metastatic breast cancer. Because of her heart condition, she's being given capecitabine (Xeloda), but only a 75% dose. Is a possible side effect of the capecitabine uncontrollable diarrhea during the period she goes off the drug?

Dr. Perry: Capecitabine is converted in the body to fluorouracil (5-FU). 5-FU causes angina (chest pain) in some individuals. If your wife's heart condition is of another sort, she may be able to take a bigger dose of the capecitabine, but I suspect the diarrhea is from the medication, and this may be the best dose for her.

Typically, patients on capecitabine have their doses reduced because of sore hands or feet, low blood counts, or diarrhea. Not everyone can tolerate the same dose.

azure9: My husband was unable to have his last treatment as his white blood counts were too low. He has had two treatments so far, and his tumor markers have almost doubled. Is this common, and what can we do to increase his white blood count? He has stage IV colon cancer.

Dr. Perry: Low white blood cells can certainly limit getting chemotherapy at full dose and on time. There are several medications, called growth factors, that can be given after chemotherapy to help the bone marrow recover in time for the next course of treatment. Alternatively, his doctor may want to reduce the dose of one or more of the medications.

Linda-NWF: After chemotherapy and surgery for lung cancer (upper right lobectomy), I had radiation therapy for six weeks. That was three years ago. Will I always have problems with scar tissue in that region and have to continually do stretching exercises? Can I expect any other side effects?

Dr. Perry: This scarring from radiation therapy is probably as bad as it's going to get. If your range of motion in your arm is limited, then stretching exercises are the answer.

I would expect any changes in lung function to have taken place long before this and would not anticipate any other changes.

Guest356: Is it common to have "weeping" eyes after the 5-FU treatments for colon cancer? I was told it would last from five weeks to five months after the last treatment, and I still have the condition 18 months later.

Dr. Perry: 5-FU sometimes causes narrowing of the duct or tube that drains tears from the eye. Your ophthalmologist (eye doctor) can confirm this diagnosis and dilate (open, enlarge) the ducts if necessary.

patW: I am 62 and was diagnosed with non-Hodgkin lymphoma two months ago. I have been receiving chemotherapy for the past month. My fingertips are raw, my hands are callused, and the skin is so thick in places that I don't have any feeling of touch. My skin cracks and peels daily. Do you have any other suggestions for my skin problems?

Dr. Perry: I'm not sure what chemotherapy you're on, but suspect it might be doxorubicin (Doxil). I suspect a visit to the dermatologist could address your problems, but in the mean time, I would try and keep your skin well lubricated with Vaseline® Intensive Care® lotion.

Apply it liberally during the day, and at night grease up and wear white gloves and white socks to bed for maximum benefit.

Guest92: Can men get hot flashes? I am taking goserelin (Zoladex) for prostate cancer and need advice on how to deal with what seem to be hot flashes.

Dr. Perry: Men certainly can get hot flashes from goserelin and similar medications. We have no better solution for men than for women, but in women venlafaxine (Effexor) reduces the number and severity of hot flashes.

Moderator: Transcripts of today's chat will be available July 26, 2005, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

AMY: My 80-year-old father is a lung cancer survivor, and he has undergone both radiation therapy and chemotherapy and has been cancer-free for several months now. He continues to collect fluid in his lungs and has a horrible cough; he cannot lie down or breathe most of the time. The doctor does not want to remove the fluid, but has him on medication for the cough.

Dr. Perry: This sounds like pleural effusion (fluid between the lung and the chest wall). This typically results from cancer nodules on the surface of the lung or chest wall that "weep" and produce fluid. This causes shortness of breath, cough, and sometimes chest pain.

The fluid can be taken off temporarily in an outpatient setting, but for long-term treatment, placement of a tube between the chest and lung for external drainage and installation of talc to make the two sides stick together is sometimes needed.

Jamie: Is there any relationship between the acuity of side effects and intended effectiveness of the drug being used?

Dr. Perry: No. Some patients experience many side effects from chemotherapy and some very few, but there is no correlation between the number of side effects and the effectiveness of chemotherapy.

glennv: What is a person to do if the pain of letrozole (Femara) and other anti-estrogens cause so much pain that it is impossible to function?

Dr. Perry: I would switch to another agent in the same class, as some patients are more tolerant of one medication than another. If that fails, then you may have to discontinue the drug.

Guest78: I am in my early 40s, newly diagnosed with a uterine sarcoma, and I just feel so stressed out about everything—from figuring out treatment to adjusting my work schedule and finding childcare. The stress is almost paralyzing me to the point that I can't make a decision. Any suggestions?

Dr. Perry: You need to let your doctor know you're experiencing this kind of stress. Ask your doctor for a recommendation of a counselor or social worker to talk to. This is also the time to ask family and friends for help with the little things that can add up to big problems.

You don't have to go through this alone and support groups for people with cancer may provide you with an opportunity to vent and realize you're not the only one with these kinds of issues.

Guest388: I have had more asthma problems since my first chemotherapy treatment. Is this a common side effect for asthmatics? What drugs are likely to damage one's lungs?

Dr. Perry: There is a long list of drugs that cause lung side effects, but very few that actually cause asthma. Methotrexate (Trexall) is perhaps the most common, and if you're receiving this drug, your doctor needs to know what you're experiencing, as he/she may want to change your medication program.

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. We want to thank Dr. Perry for lending us his time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) July 26, 2005, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net for a live chat about Nutrition and Cancer on Tuesday, August 30, 2005, from 2:00 – 3:00 PM ET.

The featured experts are Tim Byers, MD, MPH, and Colleen Gill, MS, RD, of the University of Colorado at Denver Health Sciences Center.

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

Last Updated: July 26, 2005