Managing side effects of chemotherapy

Most side effects are short term, but some may be permanent. Side effects tend to gradually improve once treatment stops and the normal, healthy cells recover. Most side effects can be managed. Some side effects from chemotherapy may not show up for many months or years. These are called late effects. Before treatment starts, talk to your doctor about whether you’re at risk of developing late effects and ways to prevent them.

Permanent side effects of chemotherapy may include damage to your heart, lungs, kidneys, nerve endings or reproductive organs. If damage to your heart muscle or lungs is a possibility, your doctor will monitor how your heart and lungs are working and adjust your chemotherapy if early changes are seen. For more information, see Heart health and cancer.

Occasionally, years after having chemotherapy, some people develop a new, unrelated cancer. The risk of this is very low, but can increase with factors such as continuing to smoke or rare genetic conditions. If you notice symptoms, even many years after treatment, ask your GP whether they could be related to the cancer treatment you received. Ask whether your hospital has a late effects clinic to help you manage any side effects you may experience after treatment. Learn more about Living Well After Cancer.

If your red blood cell count drops below normal, this is called anaemia. A reduced amount of oxygen circulates through your body, which can make you feel tired, lethargic, dizzy or breathless. These tips for coping with fatigue may be helpful. To minimise dizziness, take your time when you get up from sitting or lying down.

Your treatment team will monitor your red blood cell levels. Let them know if you have any symptoms of anaemia during your course of chemotherapy. If the levels of red blood cells drop too low, you may need a blood transfusion to build them up again.

For more information, see Fatigue and cancer. 

A low level of platelets (thrombocytopenia) can cause problems. You may bleed for longer than normal after minor cuts, have nosebleeds or bleeding gums, or bruise easily. Periods may be longer or heavier.

Your treatment team will monitor your platelet levels. If your level of platelets is too low, you may need a platelet transfusion. Ask your specialist to explain the risks and benefits of this procedure.

Contact your doctor or call Triple Zero (000) if you have persistent bleeding, such as a nosebleed, that doesn’t stop within 30 minutes.

Chemotherapy can reduce your white blood cell level, making it harder for your body to fight bacterial infections. Bacterial infections that cause sickness may come from somewhere in your body (e.g. the bowel) and are not necessarily caught from other people. Viruses such as colds, flu and COVID-19 may be easier to catch and harder to shake off, and scratches or cuts may get infected more easily. Your doctor may recommend antibiotics as a precaution against infection. There are also other ways to reduce your infection risk.

There are many types of white blood cells. One type, called a neutrophil, protects you against infection by destroying harmful bacteria and yeasts that enter the body. Chemotherapy can reduce the levels of neutrophils. This is known as neutropenia.

To boost production of new white blood cells and protect you from infection, your doctor may give you injections of a growth factor drug called granulocyte-colony stimulating factor (G-CSF). Some people may experience bone pain or tenderness at the injection site. Let your doctor know if you have any of these side effects.

Taking care with infections during chemotherapy

Reduce your risk

To prevent the spread of infection:

• check your temperature regularly and any time you feel unwell
• avoid touching your eyes, nose and mouth with your hands
• check with your doctor about having flu and COVID-19 vaccines
• ask people close to you to consider having the flu and COVID-19 vaccines
• ask family and friends with a cold, flu or other contagious infection (e.g. COVID-19 or a cold sore) not to visit while they have symptoms
• try to avoid crowded places, such as shopping centres; if this is not possible, wear a face mask
• wash your hands with soap and water before preparing food and eating, and after using the toilet
• avoid drinking or cooking with untreated water (e.g. from rainwater tanks, bores and rivers); if you rely on rainwater for drinking or cooking, boil and cool the water before using it
• eat freshly cooked foods; avoid raw foods (fish, seafood, meat and eggs) and soft cheeses; wash fruits and vegetables well before eating; prepare and store food properly.

When to seek help

Contact your doctor or go to the nearest hospital emergency department immediately if you experience one or more of the following symptoms:

• a temperature of 38°C or higher
• chills or shivering
• sweating, especially at night
• burning or stinging feeling when urinating (weeing)
• a severe cough or sore throat
• shortness of breath
• vomiting that lasts more than a few hours
• severe abdominal (belly) pain, constipation or diarrhoea
• unusual bleeding or bruising, such as heavy nosebleeds, blood in your urine (wee) or black faeces (poo)
• feeling faint or dizzy for a long time and having a rapid heartbeat
• any sudden worsening of your health.

Some chemotherapy drugs can damage nerves between the central nervous system and the arms and legs. This is called chemotherapy-induced peripheral neuropathy (CIPN). It causes tingling (“pins and needles”), numbness or pain in hands and feet, and muscle weakness in legs. For many people, peripheral neuropathy is a short-term issue. But sometimes, it can last a longer time or be permanent. If you experience numbness and tingling, tell your doctor or nurse straightaway. Your treatment may need to be changed, or the problem carefully monitored.

Wearing special gloves and socks that compress or cool your hands and feet during chemotherapy may help prevent CIPN. These can only be used with certain chemotherapy drugs, and they don’t always stop it developing. Ask your treatment team if this option is available to you.

Feeling tired and lacking energy is one of the most common side effects of chemotherapy. It’s known as cancer-related fatigue.

You may also:

• develop muscle aches and pains
• have trouble thinking clearly or concentrating
• find it difficult to do daily tasks such as getting dressed, showering and cooking.

Fatigue can affect you suddenly and it doesn’t always get better with rest or sleep. If you find it hard to do everyday things, you might feel frustrated and isolated. Fatigue caused by chemotherapy may last for months or years after the treatment. However, many people find that their energy levels return to normal 6–12 months after treatment ends.

While fatigue is a common side effect of chemotherapy, it can also be a symptom of depression. If you have continued feelings of sadness, you may have depression, and treatment may help. For more information on depression, visit Beyond Blue and talk to your healthcare team.

For more, see Fatigue and cancer and listen to Cancer Council's podcast episodes Managing Cancer Fatigue and Sleep and Cancer.

I had no idea that I would still be feeling tired 5 months after finishing treatment. I didn’t know how to make it better and I was scared that’s how it would be: that I wouldn’t go back to normal, that I would never go back to having energy again.

Judy

Whether you lose your hair will depend on the drugs prescribed. Some people lose all their hair (alopecia); others find it becomes thinner or they may lose only a little hair. Some people lose none at all. Although losing hair from the head is most common, eyebrows, eyelashes, hair from your underarms, legs, chest, beard and pubic area can also fall out.

When hair loss does occur, it usually starts during cycle 2 or 3 – or sometimes after the first cycle. It may be sudden or happen gradually. Before and while your hair is falling out, your scalp may feel hot, itchy, tender or tingly. Some people find that the skin on their head is extra sensitive, and they may develop pimples on their scalp.

It’s not unusual to feel sad or less confident. It may take time to adjust to how you look. Planning for hair loss may help you cope with it.

Hair growing back – After treatment ends, it can take 4–12 months to grow back a full head of hair. Hair usually grows about 1 cm every 4 weeks. When your hair first grows back, it may be a different colour, softer or curly (even if you have always had straight hair). In time, your hair usually returns to its original condition.

Scalp cooling – Some treatment centres provide cold caps, which may reduce hair loss from the head. Cold caps can only be used with certain drugs and some types of cancer, and they don’t always stop hair loss.

The cap is attached to a cooling unit and worn during chemotherapy. This reduces blood flow and the amount of chemotherapy drug that reaches the scalp. Some people find the cold cap uncomfortable, and the cold temperature may be painful. If you’re interested in trying a cold cap, ask your treatment centre if it’s an option for you.

It’s common for people to have difficulty concentrating, focusing and remembering things after they have had chemotherapy. This is called cancer-related cognitive impairment. Other terms used to describe this include “chemo brain”, “cancer fog” and “brain fog”.

Thinking and memory changes may be caused by treatment or medicines, the cancer itself, fatigue and sleep problems, or feeling stressed or depressed. These problems usually improve with time, although some people can experience issues for years. Tell your doctor about any thinking and memory changes you’re having.

Some chemotherapy drugs can damage healthy cells in the mouth and cause mouth sores, ulcers (oral mucositis) or infections. Chemotherapy treatment may also reduce the amount of saliva (spit) in your mouth, make your saliva thick or sticky, or make your mouth dry. This is called xerostomia or dry mouth. If you notice any sores, ulcers or thickened saliva, or if you find it difficult to swallow, tell your doctor.

To learn more, see Mouth health and cancer treatment and Taste and smell changes.

Some chemotherapy drugs may cause your skin to peel, darken or become dry and itchy. During treatment, and for several months afterwards, your skin is likely to be more sensitive to the sun.

You may find your nails also change and become darker than usual or develop ridges or white lines across them. Your nails may also become brittle and dry or lift off the nail bed. These changes usually grow out. Avoid having your nails done at a nail salon, as this can increase the risk of infection during chemotherapy. 

Chemotherapy can affect your sense of smell and you may notice that your body odour is unpleasant. Talk to your cancer care team if you’re concerned about a change in body odour.

It’s common for your appetite to change during chemotherapy. Sometimes you may not feel hungry, or you may prefer different types of food. The drugs may also temporarily change how food tastes.

Chemotherapy can make you feel sick (nauseated) or make you vomit. Not everyone feels sick during or after chemotherapy, but if nausea affects you, it usually starts a few days after your first treatment. Nausea may last a short time or for many hours and you may also vomit or retch (when you feel the need to vomit but can’t). Sometimes nausea lasts for days after treatment.

Often the best way to manage nausea is to prevent it from starting, so you’ll usually be given anti-nausea (antiemetic) medicine before, during and after your chemotherapy sessions. Anti-nausea medicine helps most people, but finding the right one can take time. If nausea or vomiting continues after using the prescribed medicine, let your nurse, doctor or pharmacist know early so that another medicine can be tried. Steroids may also be used to manage nausea and improve appetite.

Appetite changes, nausea or vomiting may lead to weight loss. Losing weight during chemotherapy can make some side effects worse or cause delays to your treatment. A dietitian can help you choose the best foods to minimise weight loss.

Being unable to keep liquids down because of vomiting can make you dehydrated. Signs of dehydration include a dry mouth and skin, dark urine (wee), dizziness and confusion. It’s not safe to be left alone if you’re vomiting a lot, as the confusion may make it difficult to realise you have become seriously dehydrated. If you think you may be dehydrated, contact your doctor.

Some chemotherapy drugs, pain medicines and anti-nausea medicines can cause constipation or diarrhoea. If your bowel habits change during your treatment, talk to your doctor, pharmacist or nurse.

For some people, there will be ongoing bowel problems after cancer treatment has finished.

See Nutrition for people with cancer for more information on staying well nourished and meal ideas.

Your doctor may recommend that you have a hearing test before you start treatment, and this may be repeated before each treatment cycle. You may be at risk of losing the ability to hear high-pitched sounds. Some types of chemotherapy drugs may also cause a continuous ringing noise in the ears known as tinnitus. These changes can happen alone or together, and can be temporary or permanent. Let your doctor know if you notice any change in your hearing.

This can be a symptom of a blocked tear duct, which can be caused by some chemotherapy drugs. Massaging the area regularly with a small towel soaked in warm water (compress) and using eye drops can help clear blockages. Let your cancer care team know if this issue is ongoing.

You may notice a lack of interest in sex or a loss of desire (libido), or you may feel too tired or unwell to want to be intimate. You may also feel less confident about who you are and what you can do.

There may be physical reasons for not being able to have sex or not being interested in having sex (e.g. vaginal dryness or erection difficulties). Changes in how you look can also affect feelings of self-esteem and, in turn, your interest in sex.

If you have a partner, it may be helpful for them to understand the reasons why your libido has changed, and to know that people can usually have a fulfilling sex life after cancer, but it may take time. Some partners may feel concerned about having sex. They might be worried about injuring or hurting you, or being exposed to chemotherapy drugs during sex.

Even if some sexual activities are not always possible, there are many ways to express closeness. Talking openly to your partner about how you’re feeling can be difficult but it’s often very helpful. It’s important to take time to adapt to any changes. If you’re worried about changes to how you feel about yourself, your relationships or sexual functioning, you may find talking to a psychologist, sex therapist or counsellor helpful.

To learn more, see Sex, intimacy and cancer and listen to Cancer Council's podcast episode Sex and Cancer.

In most cases, your doctor will advise you to use some form of barrier contraception (condom, female condom or dental dam) during treatment and for a while after. This is to protect your partner from any chemotherapy drugs that may still be in your body fluids.

As chemotherapy drugs can harm an unborn baby, your doctor may talk to you about using contraception for some months after chemotherapy. Although chemotherapy often affects fertility, it doesn’t always. If you’re in a heterosexual relationship and sexually active, you’ll need to use a reliable form of contraception to avoid pregnancy while having treatment. Talk to your specialist immediately if you or your partner become pregnant.

Chemotherapy can affect your ability to have children (fertility). This may be temporary or permanent. If you may want to have a child in the future, talk to your doctor before starting chemotherapy about how the treatment might affect you and what options are available. Eggs (ova), embryos, ovarian tissue or sperm may be able to be stored for use at a later date. This needs to be done before chemotherapy starts. In some cases, hormone injections can reduce activity in the ovaries and protect eggs from being damaged by chemotherapy. 

Effects of chemotherapy on ovaries

Some chemotherapy drugs can reduce the levels of hormones produced by the ovaries. This can cause your periods to become irregular or even stop for a while, but they often return to normal within a year of finishing treatment. If your periods don’t return, the ovaries may have stopped working, causing menopause. After menopause, you can’t get pregnant naturally.

Signs of menopause include hot flushes, night sweats, aching joints and dry or itchy skin. In the long term, menopause – particularly when it occurs under 40 – may cause bones to become weaker and break more easily. This is called osteoporosis. Talk to your treatment team or GP about ways to manage menopause symptoms.

Effects of chemotherapy on sperm

Some chemotherapy drugs can lower the number of sperm produced and reduce their ability to move. This can sometimes cause infertility, which may be temporary or permanent. The ability to have and keep an erection may also be affected (erectile dysfunction or impotence), but this is usually temporary. If erection issues are ongoing, talk to your doctor.

For more, see Fertility and cancer.

All my life I wanted to be a father. I didn’t want cancer to ruin my chances, so I stored my sperm before treatment started. I think of this as a bit of an insurance policy.

Zac