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Chemotherapy

Explained

Side effects

&

How to manage them

Advice Assistance Advocacy Awareness Support Wellness

For all Breast Cancer Patients and Survivors, we offer many free services here in the Cayman Islands

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Introduction

We hope that this information helps you to discuss any questions you have with your Medical Team. The Breast Cancer Foundation are here to help you, contact details are contained in this leaflet, and full details of the free services we offer can be found on our website www.breastcancerfoundation.ky

Chemotherapy for breast cancer uses drugs to target and destroy breast cancer cells. These drugs are usually given directly into a vein through a needle or as a pill. Chemotherapy for breast cancer frequently is used in addition to other treatments, such as surgery, radiation, or hormone therapy. Receiving chemotherapy for breast cancer may increase the chance of a cure, decrease the risk of the cancer returning, alleviate symptoms from the cancer or help people with cancer live longer with a better quality of life. If the cancer has recurred or spread, chemotherapy may control the breast cancer to help you live longer. Or it can help ease symptoms the cancer is causing. Chemotherapy for breast cancer also carries a risk of side effects — some temporary and mild, others more serious or permanent. Your doctor can help you decide whether chemotherapy for breast cancer is a good choice for you.

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Why is chemotherapy given: Chemotherapy for breast cancer may be given in the following situations:

Chemotherapy after surgery for early breast cancer After you have surgery to remove a tumor from a breast, your doctor may recommend

chemotherapy to destroy any undetected cancer cells and to reduce your risk of the cancer recurring. This is known as adjuvant chemotherapy.

Your doctor may recommend adjuvant chemotherapy if you have a high risk of the cancer recurring or spreading to other parts of your body (metastasizing), even if there is no evidence of cancer after surgery. You may be at higher risk of metastasis if cancer cells are found in lymph nodes near the breast with the tumor. When considering adjuvant chemotherapy, ask your doctor about how much the chemotherapy will reduce your chance of the cancer coming back. Together you can weigh this decrease in risk against the side effects of the chemotherapy. Also discuss with your doctor other alternatives, such as hormone-blocking therapy, that might be effective in your situation. Chemotherapy is sometimes given before surgery (neoadjuvant therapy) to shrink larger tumors. This may:

Allow the surgeon the best chance of removing the tumor completely Enable the surgeon to remove only the tumor, rather than the entire breast Decrease the extent of disease in lymph nodes, thus allowing for less invasive lymph node

surgery Decrease the chance the cancer will return Enable evaluation of the tumor response to therapy, which helps clarify prognosis and the

best chemotherapy drug choice

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Neoadjuvant therapy is often used for:

Inflammatory breast cancer HER2-positive breast cancer Triple-negative breast cancers High-grade tumors Cancers that have spread to the lymph nodes Larger tumors Treatment to reduce breast cancer risk

Preventive medications (known as chemoprevention) reduce the risk of breast cancer in women with a high risk of the disease. They usually include estrogen-blocking medications, such as selective estrogen receptor modulators and aromatase inhibitors. These medications carry a risk of side effects, so doctors reserve these medications for women who have a high risk of breast cancer. Discuss the benefits and risks with your doctor.

Chemotherapy as the primary treatment for advanced breast cancer is when the breast cancer has spread to other parts of your body and surgery is not an option, chemotherapy can be used as the primary treatment. It may be used in combination with targeted therapy. The main goal of chemotherapy for advanced breast cancer is generally to improve quality and length of life rather than to cure the disease. Risks of Chemotherapy Chemotherapy medications travel throughout the body. Side effects depend on the drugs you receive and your reaction to them. Side effects may get worse during the course of treatment. Most side effects are temporary and subside once treatment is finished. In some cases, chemotherapy can have long-term or permanent effects.

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What are the most common side effects of chemotherapy treatments?

Short-term side effects

In the process of targeting fast-growing cancer cells, chemotherapy drugs can also damage other fast-growing healthy cells, such as those in the hair follicles, bone marrow and digestive tract. Several chemotherapy drugs can affect nerve endings in your hands and feet, leading to numbness, pain, burning or tingling, sensitivity to cold or heat, or weakness in your extremities. These side effects often go away after treatment is finished or within a year after completing chemotherapy. In some cases, they may be long lasting. “Chemo brain,” “chemo fog” and “chemo memory” are terms used to describe controversial and little-understood short-term memory and concentration problems that may occur after chemotherapy. In most cases, these problems go away within a year of completion of the chemotherapy. Common short-term side effects include:

Hair loss

The Breast Cancer Foundation has supplied all three chemotherapy units in the Cayman Islands with cold cap machines, please see our website for details of the use of cold caps.

Electronic cold cap Manual Cold Cap

If you choose not to use the cold caps to retain your hair during chemotherapy, then the Foundation has a large selection of wigs and scarves for you to choose from. The Foundation can also arrange a private hair appointment (at home if desired) to shave your hair once it has started to fall out, which will normally be after your 2nd round of chemotherapy.

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Fatigue

Tell your doctor if you are experiencing fatigue, then try to move as much as possible, maybe some gentle exercises, under the supervision of your medical professional, also take time to relax. Massage, acupuncture, reflexology can help and are all available on the Wellness Program via The Breast Cancer Foundation. Try to eat well, if your insurance does not cover you to see a dietician, (which is what we would recommend to get the best advice on your diet), then the Foundation can cover this cost for you. Try to practice good sleep habits if you are having trouble sleeping them the Foundation can help by referring you to a professional for instruction in therapies that might help, such as hypnotherapy, mindfulness/meditation. Consider learning these techniques and see a specialized counselor/therapist.

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Loss of appetite

Try to eat to eat small meals or snacks, every two to three hours, instead of three large meals a day (become a grazer). Do not expect to eat regular size meals. Foods that are high in protein or calories are good snacks to have handy. Examples; milk shakes, cheese, fruits, peanut butter, nuts, crackers and juices. Eat foods that are rich in calories and nutrients avoid low-calorie foods that fill you up, such as lettuce, broth and diet soda. When choosing beverages, select nutrient-dense fluids such as milk, milk shakes, juice, and punch-type drinks. Avoid heavy meals, greasy or fried foods, and foods that cause gas. Examples of gas-producing foods include beans, cauliflower, broccoli, cabbage, and carbonated drinks. Prepare food that is colorful and appealing to the eye. If you feel you need help in nutrition, please contact the Breast Cancer Foundation.

Nausea and vomiting

One of the biggest pitfalls of undergoing chemotherapy can be dealing with nausea. Not everybody will experience this uncomfortable side effect, and often times, symptoms may be only mild. Even mild nausea, however, can have a significant impact on how much food one is able to eat, contributing to weight loss. Knowing how to manage nausea is important to staying healthy during your treatment. The following are suggestions to minimize your discomfort:

Avoid your favorite food. Do not eat your favorite food if you are feeling nauseated. This may create a negative association with that food and the next time you try to eat it, your favorite food may cause you to feel queasy. Rather, have foods that are easy to digest such as crackers, toast, yogurt, potato, broth, or rice.

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Talk to your doctor about nausea medications. Common medications for nausea include ondansetron (Zofran) and prochlorperazine maleate (Compazine). It is best to take these medications about an hour before eating. This will help you maximize how much you can eat and allow you to enjoy your meal more.

Avoid strong smells. Half of our taste sensors come from our nose, so avoid the kitchen while your family or friends are cooking (this would be a good time for a nap in your bedroom). Open a window to help neutralize any smells.

Avoid warm foods. Cold foods like yogurt and ice cream are often well tolerated. Try letting your warm food cool down for 30 minutes before eating, if you cannot wait, place your warm dish in a large bowl of ice to it cool down quickly.

Eat every 2-3 hours. Sometimes an empty stomach causes a queasy stomach. Try to not let your stomach get completely empty by snacking on pretzels, crackers, toast, yogurt, cheese, or a milkshake.

Eat what you want to eat. If you feel like having macaroni and cheese, and that appeals to you, then by all means, eat some macaroni and cheese. Breakfast food for dinner? Go for it! Do not try to force yourself to eat a meal that causes your stomach to turn at the thought of it. Some patients are turned off by salty foods, some by sweet foods. Some patients find that everything tastes very bland and enjoy extra herbs or spices. Adjust how your food is prepared so that is appeals to you. This is not a one size fits all approach to eating.

Drink liquids in-between meals/snacks. Filling your stomach up with liquids during mealtime there will be less room for food! You will feel full faster if you drink too much with your meals. Staying hydrated is important, so sip on liquids in between your meals. Small sips during mealtimes should be well tolerated.

Use ginger and peppermint. Ginger and peppermint are age old remedies used for treating nausea. Make a cup of ginger or peppermint tea, or purchase ginger or peppermint candies. Put a drop of peppermint essential oil on a tissue and bring it with you to inhale. If you know you like the scent of peppermint, you could put a drop underneath the collar of your shirt or pin a handkerchief with a drop underneath your shirt.

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Constipation or diarrhea

For constipation

Increase your fiber intake. About 25 to 50 grams of fiber is recommended per day Drink plenty of water or juices. Drinking liquids helps add moisture to your stool, making

it easier to pass Get some exercise Try over-the-counter stool softeners or laxatives Ask about an enema

Diarrhea

Eat small meals more frequently Avoid foods that trigger or worsen diarrhea Choose foods that are easy on your stomach Drink plenty of clear liquids Give probiotics a try Take over-the-counter medications

Mouth Sores

Avoid painful foods. Stay away from acidic foods and spicy foods that could further irritate your mouth

Eat small meals more frequently. Cut your food into small pieces and eat slowly Use a straw Continue cleaning your mouth, mouth washes can also be helpful Joan Lunden’s tip, each ice chips during chemotherapy – it worked for her!

(Joan visited the Cayman Islands in 2015 to speak at the Breast Cancer Gala Dinner – her book “Had I known” some might find very helpful-this book is available in the Breast Cancer Foundations lending library)

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Nail changes

During treatment for breast cancer you may notice some changes in the color or thickness of your fingernails or toenails or changes around the nail bed. Your nails may look bruised -- turning black, brown, blue, or green. People with darker complexions notice the color change more. You may develop blemishes on your nails such as a horizontal or vertical line, or small indentations. These marks reflect the timing of chemotherapy. You may have multiple lines or indentations that mark the different cycles of chemotherapy. These spots are not permanent and will grow out with the nail. Your nails may become thin or brittle. Your nails probably will not grow as long as they used to and may tend to break more easily. The nail can lift completely off the nail bed or fall off in some cases. If the nail is not tightly bound to the nail bed, it can be a site for bacteria to enter and cause infection. The nail bed may become dry and you may have frayed cuticles. You may develop ingrown nails on your fingers or toes. If you are experiencing nail changes, your risk of infection may increase. A nail infection can be serious if your immune system is compromised from chemotherapy. If you have lymphedema, a nail infection can make it worse. The following tips can cover up any nail blemishes and help keep your nails free from infection:

Before you start chemotherapy, have your nails painted as dark as possible, this can help to minimize the damage.

Keep nails trimmed and clean to reduce the risk of infection. Wear gloves when gardening or housecleaning to avoid infection. Paint your nails to hide blemishes and increase nail strength. Make sure to use a nail polish

you have used before to decrease the risk of having an allergic reaction. Remove nail polish with a non-acetone-based remover -- it can be less drying than an

acetone-based remover.

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Do not bite or tear at your nails. This habit can put you at risk for infection. Buy thin cotton gloves that you can wear around the house to help you break this habit.

Do not pick at your cuticles if you have dry skin around the nail bed or frayed cuticles. Use a cuticle remover cream or gel to keep cuticles tidy. You can push your cuticles back

gently using a wooden cuticle stick. Massage cuticle cream into the nail area to prevent dryness, splitting, and hangnails. Limit the time your hands are in water. Excessive exposure to water can lead to fungal

infections in the nail bed. Do not use artificial nails. Artificial nail adhesives have chemicals that may cause an

allergic reaction, such as swelling or inflammation. Fake nails also can trap bacteria that may cause infection.

If you develop an ingrown toe or fingernail, try soaking it in warm water and putting some antibiotic cream on the area. If the area is still painful or there is pus or redness that seems to be spreading, call your doctor immediately.

Tell your doctor if you have any signs of inflammation or infection. If you are having pain or draining fluid from your nail, call your doctor immediately.

The Breast Cancer Foundation works with highly trained professionals who have been carefully selected to be able to work with patients undergoing chemotherapy. There is no cost to you for this service under the Wellness Program.

Skin Changes

Some types of chemotherapy can cause your skin to become dry, itchy, red or darker, or peel. You may develop a minor rash or sunburn easily; this is called photosensitivity. Some people also have skin pigmentation changes. Your nails may be dark and cracked, and your cuticles may hurt. If you received radiation therapy in the past, the area of skin where you received radiation may become red, blister, peel, or hurt. This is called radiation recall. Signs of an allergic response to chemotherapy may include a sudden or severe rash or hives or a burning sensation.

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Talk with your health care team to learn if you should manage these problems at home. Depending upon the treatment you are receiving, your health care team may advise you to take these steps:

Use only recommended skin products. Use mild soaps that are gentle on your skin. Ask your nurse to recommend specific skin products.

Moisturize your skin. Use recommended creams or lotions to prevent your skin from becoming dry and itchy. Irritated skin can become infected. Ask about special creams or ointments for severely dry, itchy, or painful skin.

Protect your skin: Use sunscreen and sun-protective lip balm. Wear a loose-fitting long-sleeved shirt, pants, and a hat with a wide brim when outdoors to prevent sunburn. If you are receiving radiation therapy, do not use heating pads, ice packs, or bandages on the treatment area. You may want to shave less often and use an electric razor or stop shaving if your skin is tender and sore.

Prevent or treat dry, itchy skin. Avoid products that list alcohol or fragrance as an ingredient since they can dry or irritate your skin. Your nurse may suggest you add colloidal oatmeal to your baths, as it can reduce itching. Take short showers or baths in lukewarm, not hot, water. Put on skin cream or ointment that is recommended by your nurse after drying off from a shower but while your skin is still a little damp. Apply a cool washcloth or ice to dry, itchy skin.

Learn about treatments for irritating or painful skin rashes: Sometimes skin problems need medical treatment. Your rash may be treated with a medicated cream (topical corticosteroids) or with medicine that you take as a pill (oral corticosteroids or antibiotics).

Increased risk of developing infection (due to fewer white blood cells that help fight infection)

After chemotherapy, if your white blood cells are low, you are more likely to get infections. Any infection can also worsen quite quickly. Because of the chemotherapy your immune system is not as good as before. So simple infections can now become life threatening within hours if not treated. Your nurse or doctor will tell you about the symptoms of infection to look out for, and when you need to call your advice line or return to hospital. Not all chemotherapy drugs affect your bone marrow and increase the risk of infection, but many do. It depends on:

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Which drug you have The amount (dose) of the drug – the higher the dose the more likely it is to affect your

bone marrow Your age – chemotherapy is more likely to affect your bone marrow function if you are

elderly Your general health The type and stage of your cancer When you are most at risk These effects on your bone marrow usually begin around 7 to 14 days after each

treatment. This is when your blood counts are usually at their lowest point. This is called nadir. They usually return to normal between 21 and 28 days.

When your blood cell counts are at their lowest you can feel very tired (fatigued). Some people also say they feel depressed. This can be hard to deal with and make you wonder if you really want to go on with your treatment. This is usually because it is also affecting your red blood cells. Things should improve as your blood counts rise. You will start to feel better again before your next treatment. Unfortunately, they will go down again after each treatment. But once your treatment is finished your blood cell counts will return and stay at normal levels. To make sure your bone marrow is working well you will have regular blood tests. Sometimes your doctor may give you a course of antibiotics during your chemotherapy to help fight off an infection or stop you getting one. If chemotherapy damages your infection-fighting blood cells, your doctor may adjust your doses or add medications that help your bone marrow to recover more quickly.

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Long Term Effects

Certain chemotherapy drugs for breast cancer can cause long-term side effects, including:

Infertility

One possible side effect that may not go away is infertility. Some anti-cancer drugs damage ovaries. This may cause menopause symptoms, such as hot flashes and vaginal dryness. Menstrual periods may become irregular or stop (amenorrhea). If ovulation ceases, pregnancy becomes impossible. Depending on your age, chemotherapy may induce a premature permanent menopause. Discuss with your doctor your risk of permanent menopause and its consequences. See the BCF website for more details in our information leaflet “Menopause Symptoms Due to BC Treatments”. If you continue to menstruate, you may still be able to get pregnant, even during treatment. But because the effects of chemotherapy are dangerous to the fetus, talk with your doctor about birth control options before treatment begins.

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Osteopenia and osteoporosis

Women who experience menopause early because of chemotherapy may have a higher risk of the bone-thinning conditions osteopenia and osteoporosis. It is generally recommended that these women have periodic bone density tests and, possibly, treatments to prevent further bone loss.

Heart damage

Chemotherapy carries a small risk of weakening the heart muscle and causing other heart problems.

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Leukemia Rarely, chemotherapy for breast cancer can trigger a secondary cancer, such as cancer of the blood cells (leukemia), several years after the chemotherapy was completed.

Other side effects

Feelings of fear, sadness and isolation can compound the physical side effects of chemotherapy, both during and after treatment. During chemotherapy, you have regular contact with and support from oncologists and nurses. Everyone involved is working toward the same goal — completion of treatment with the best possible outcome. When it is over, you can feel as if you are alone, with no one to help you return to normal life or deal with fears of breast cancer recurrence. Consider talking with a mental health professional who works with people who have cancer. It may also help to talk with someone who has been in the same situation. Connect with others through a cancer-survivor hotline, support group or online community.

The aim of the Breast Cancer Foundation is to help anyone living in Cayman who is worried or has diagnosed with Breast Cancer at any time, the services of the Foundation are free to those who qualify.

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Find us on

Website

www.breastcancerfoundation.ky

info@breastcancerfoundation.ky

(345)923 1135 (345)936 1135

(345) 938 1135 (345) 936 1136

#19 Grand Harbour – Grand Cayman

BCF would like to thank the following in helping to create this leaflet:

The Foundation’s Medical Advisor –

Dr. Virginia Hobday MBE MB. BS, MRCGP, DFFP, M.Phil

We also acknowledge American Cancer Society, MacMillan Cancer Care (UK), Cancer Research UK,

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About the Foundation

The Foundation was started in 2008, this was the 10th Anniversary of the passing of Brenda Tibbetts-Lund, who had a very courageous battle with breast cancer, even before her diagnosis, Brenda had been very active in the Cayman community promoting breast health. Having sponsored the Brenda Tibbitts Lund walk/run in her honour, Kim Lund wanted to do something special in 2008. That is when the Breast Cancer Gala Dinner idea was born, all funds raised from the Gala Dinner were to benefit breast cancer patients here in Cayman. After that gala, the realization that there was an enormous demand for funds for breast cancer patients culminated in Kim Lund and James Bovell (Owners/Brokers at RE/MAX), along with John Broadbent Cayman Islands to take the decision to found a not-for-profit charity (NPO 124) and make the Gala Dinner and Annual Event, since its inception it has become one of the most anticipated and prestigious black (pink actually) tie events on the island. The Foundation was created originally to provide sponsorship for the Lions Club of Tropical Gardens for the Brenda Tibbitts-Lund annual walk and to provide financial support for the CI Cancer Society for the assistant they give out to breast cancer patients, this is still the case over twelve years later. The Foundation has grown to be so much more. In 2015 the Foundation launched its own Wellness Program which provides a multitude of holistic and medical services to anyone going through breast cancer. The organization also works diligently in raising Awareness and providing local practitioners with the training, skill, and medical equipment to be able to help breast cancer patients in the best way possible this along with providing mammograms where needed and a full, prosthetic/bra service for those who have undergone breast surgery.