To investigate whether a relationship between chemotherapy - associated adverse events and treatment efficiency exist, we have analyzed the toxicity, objective and survival data of 303 patients9190 men and 113 woman)who received first or second line chemotherapy between 1998-2001. Patients were divided into two groups. Group 1 had positive treatment effects, which included complete response.
The second group was rated progressively during chemotherapy. Out of the 303 patients 245 were categorized in G1 -58 patients in G2 and only 6 patients had no side effects and 297 patients had at least one adverse event. In all 252 patients (83%) they had Hematological side effects and 289 patients (95%) had non Hematological side effects.
In conclusion the result of the analysis of 303 patients with cancer suggested that occurrence of side effects during chemotherapy is independent prognostic indicator of response, patients should receive adequate drug dosages, which may warrant individualized dose escalation. However, treatment associated side effects should not be too sever and thus interfere with the patient quality of life (schuell, T., 2005).
Adverse Reactions of Chemotherapy
Chemotherapy is treatment with anti-cancer drugs, given to destroy or control cancer cells. A single drug may be given or several different drugs may be given together. This is called combination chemotherapy. The aim of the treatment will depend on the type of cancer you have and how advanced it is.
Chemotherapy drugs enter your bloodstream and therefore reach all parts of your body. Chemotherapy drugs destroy cancer cells by damaging them so they can't divide and grow. The drugs can also affect normal cells which are growing and dividing quickly and this can cause side effects. These are usually temporary because healthy cells quickly recover and permanent damage is rare with most chemotherapy treatments.
Sometimes chemotherapy is used on its own in cancers that respond well to this treatment, however, chemotherapy is often used with other treatments. It may be given before surgery or radiotherapy to shrink the tumor or after these treatments to help destroy any cancer cells that may remain. The aim is to reduce the likelihood of the cancer returning in the future. Palliative chemotherapy is given if the cancer has spread to other parts of the body and the aim is to help relieve symptoms.
The length of treatment will depend on how well the disease responds to the drugs. Doctors may choose to give the treatment for several weeks and then check on patient's progress. Overall, it may take several months to complete the course of chemotherapy.
Doctor will monitor patient's progress throughout treatment. There are several tests which may be repeated during treatment including scans, x-rays and blood tests. These tests check on patient's health and the way chemotherapy is affecting him. They will vary from person to person so if patients are not sure why they're having a particular test, they should ask doctor or nurse. Sometimes, as a result of the tests during treatment, the chemotherapy plan may be changed. For example, if the blood test shows that patient 'blood count' is low, the doctor may decide to give patient a longer rest period between cycles or reduce the dose of the drugs.
This paper will be on adverse reaction of chemotherapy. I will discuss about bone marrow suppression, gastrointestinal toxicity, dermatology toxicity, renal toxicity, bladder toxicity, sex organ and sexuality disfunction and depression .
- Definition of chemotherapy
"Chemotherapy is a cytotoxic drug used to control the growth cancerous cells or destroy abnormal cells. It is used to slow the growth of cancer cells or to keep cancer from spreading to other parts of the body, also if cancer is surgically removed, chemotherapy may be used to keep cancer from coming back." (The cancer chemotherapy hand book 2003).
- Causes of side effects
Because cancer cells may grow and divide more rapidly than normal cells, many anticancer drugs are made to kill growing cells, but certain normal cells also can be affected. This damage to normal cells causes side effects. (The cancer chemotherapy hand book).
Persons may have none or just a few of the side effects. The kinds of side effects and how severe they are depend on the type and dose of chemotherapy the person gets and how his body reacts, most side effects gradually disappear after treatment and some causes permanent changes or damage e.g. (heart, lungs, nerves, kidneys).
Patients should enquire about possible chemotherapy side effects. They may suffer from it with their medical team (Doctors and nurses) and period of time it last and when he/ she need to seek medical treatment.
1-Bone marrow suppression
The three major problems of bone marrow depression are (The cancer chemotherapy hand book (2003)):
1.1. Anemia
Is reduction of the concentration of hemoglobin and the circulating blood cells (RBC) mass. Anemia affects the person's energy level, functional ability, mood, and overall quality of life. The physical symptoms the person will feel dyspnea, dizziness, headaches and tachycardia. Continues assessment and monitoring of patients hemoglobin are required for early detection and treatment for any abnormality.
Figure 1-1
1.2. Leucopenia - Granualocytopenia
Leucopenia is a decrease in the total number of circulating white blood cells (neutrophils, eosinophils and basophils) the cells responsible to fight against infection, so reduction in its number causes local and systemic infections. The signs and symptoms of infection are high temperatures more than 38ï‚°C, tenderness, swelling, chills, rash, increased respiration, malaise, headaches and cough. Early assessment, prevention, detection and treatment can stop further complication patients may safer from it.
Figure 1-2
1.3. Thrombocytopenia
Thrombocytopenia is the platelet count less than 10.000 cells/mm. this is seriously dangers as patients are at high risk for CNS bleeding, GI bleeding or respiratory tract hemorrhage and good observation for skin for any petechiae, porpura and bruising are needed. Also tests of stool, urine and vomits for presence of blood. This will help to prevent or reduce the bleeding risk in patient's .
Figure 1-3
2. Gastrointestinal toxicity
2.1. Nausea & Vomiting
Nausea and vomiting which is associated with chemotherapy are most distressing side effects with treatment. Nausea is unpleasant sensation with discomfort in the epigastric, throat and abdomen. While vomiting is the forceful expulsion of the content of the stomach through the mouth or nose . Patients will feel weakness, dizziness, headaches, low blood pressure and bradycardia or tachycardia. The patients vomiting differ from acute (within the first 24 hours) or delay (after 24 hours of treatment and may last 1-7 days). Early intervention implementing for nausea and vomiting can prevent sever dehydration and weight loss or further other complications.
2.2. Diarrhea
Diarrhea in cancer patients may be related to a number of causes, such as anxiety, a change in diet, infection, radiation, medication, tumor, obstruction and chemotherapy.
The GI tract is susceptible to chemotherapy toxicity because of the rapid turnover of the mucosal cells. Diarrhea observed in 75% of patients who received chemotherapy. Some patients report prolonged or severe diarrhea that requires intervention to minimize complications of dehydration, electrolyte imbalance, weakness, decreased caloric intake and weight loss.
2.3. Constipation
Constipation is defined as difficult passage of hard, dry stool with excessive straining, incomplete evacuation, abdominal cramping, discomfort, distention, feeling of fullness and pressure in the rectum. The cause of constipation is immobility, older age, less oral intake, drugs, metabolic abnormalities and chemotherapy effects on the GI mucosa membrane. Careful monitoring for stool impaction to protect the integrity of rectal mucosa and bleeding .
3. Dermatology Toxicity
3-1-Alopecia
Alopecia is hair loss as the effect of chemotherapy on hair folliculate and cell mitosis causes cell destruction of hair roots associated with complete or minimal alopecia. Hair is very important part of physical appearance and loss it cause fear, anxiety, disturbing self and body image, negativity in coping and social instruction . The degree of distress may be minimized by adapting changes of focus from physical value, Further more family and health care support. The hair will regroup back within three five month of stop treatment.
Figure 3-1
3.2. Extravasation
Extravasation is the infiltration of a vesicant drug from an intravenous line in to surrounding tissue can occur with either a peripheral or a central venous catheter. Extravasation occurs when a peripheral catheter erodes through the vessel wall at a second point, when increased venous pressure causes leakage around the original veinopuncture site, or when a needle pulls out of the vein. Signs and symptoms of extravasation include edema and changes in the site's appearance and temperature, such as swelling, blanching, and coolness. The patient may complain of pain or a feeling of tightness around the site. Vesicant drugs or solutions (such as certain antineoplastic drugs) cause severe tissue injury or destruction when they extravasate. Possible consequences include necrotic ulcers, infection, disfigurement, reflex sympathetic dystrophy syndrome, and loss of function. Selection of a good vein site and carful chemotherapy administration and observation during drug flow can minimize the risk of extravasation.
Figure 3-2
4. Renal Toxicity
Impaired renal function and nephrotoxicity is due to the use of nephrotoxic chemotherapy drugs. High dose therapy lead to more renal toxicity, acute renal function failure and hemolytic uremic syndrome are potentially serious and fatal complication. Before initiating therapy it is essential to assess renal function and evaluate risk factors.
Figure 4.1
5. Bladder Toxicity
Contact of the bladder wall with toxic drugs produces mucosal erythema, inflammation, ulceration, necrosis, diffuses small-vessel hemorrhagic oozing and reduced bladder capacity. Symptoms include hematuria and dysuria, and with prolonged use of these drugs may cause bladder carcinoma. Use of good hydration and discontinuation of treatment depends on the degree of toxicity.
Figure 5.1
5.6 - Sexual Organs & Sexuality Disfunction
Chemotherapy may but does not always affect sexual organs (testis in men, vagina and ovaries in women) and functioning in both men and women. The side effects that might occur depend on the drugs used and the person's age and general health.
A-Men
Chemotherapy drugs may lower the number of sperm cells and reduce their ability to move. These changes can result in infertility, which may be temporary or permanent. Infertility affects a man's ability to father a child, but not a man's ability to have sexual intercourse. Other possible effects of these drugs are problems with getting or keeping an erection and damage to the chromosomes, which could lead to birth defects.
B-Women
Effects on the ovaries anticancer drugs can affect the ovaries and reduce the amount of hormones they produce, some women find that their menstrual periods become irregular or stop completely while having chemotherapy. Related side effects may be temporary or permanent.
7- Depression
Depression is a mental state characterized by feelings of extreme sadness, a loss of energy, trouble with appetite or sleeping, or suicidal thoughts. People who are depressed lose interest in things that once made them happy. Depression may cause feelings of worthlessness and hopelessness, leading to problems in dealing with simple daily tasks, such as getting dressed. An estimated 15-25% of cancer patients suffer from depression ,the main symptoms of depression are feelings of sadness that won't go away, suicidal thoughts or attempts, fascination with death , loss of hope or worth , lack of energy , sleeping too much or too little, loss of interest in food or overeating , inability to enjoy typically fun things , difficulty making decisions and performing tasks ,finally anxiety, and irritability.
Depression is a common side effect in cancer patients and is not a sign of weakness. Diagnosing patient problems and getting help for them as soon as possible is important in overcoming depression. Discussion of patient feelings with treating doctor, who may be able to refer him to a counselor or other mental health professional . The doctor might also recommend medication to help relieve the symptoms.
Figure 7-1
In conclusion chemotherapy is a cytotoxic drug used to cure, control growth, shrink and destroy the tumor and at the same time affect and destroy the normal cells, which lead to many side effects. Different chemotherapy has different short term and long term side effects, some of them causes Depression of bone marrow (anemia, bleeding, and infection), GI toxicity (nausea, vomiting, diarrhea, constipation, stomatitis). Dermatology toxicity (alopecia, extravasations), renal and bladder toxicity and lots of problems e.g. cardiopulmonary, neurological, gondola toxicity, fatigue, pain, memory changes that could not be mentioned now.
But remember that the side effects depend on many factors, which are duration of drug use, person's general health, the dose and way of giving the drugs. Some side effects are serious and need medical treatment, and most of the adverse effects disappear after the treatment stop. If the person does not get side effects, it does not mean that the treatment is not working, at the end always discuss the possible side effects with your Doctor and health care team.
