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Managing Chemotherapy Side Effects


What is Chemotherapy?

Chemotherapy or “chemo” medications may cure cancer, decrease relapse rates, and shrink tumors that cause pain and other symptoms (National Cancer Institute [NCI], 2015). Chemo halts or slows the division of fast-growing cancer cells. However, chemo also affects normal cells that divide quickly throughout the body and therefore may cause numerous side effects.

Normal cells that are typically affected by chemotherapy include (American Cancer Society [ACS], 2020):

  • Bone marrow where red blood cells are produced
  • Hair follicles
  • Oral, gastrointestinal (GI), and reproductive cells
  • Cells of major organs such as the heart, kidney, bladder, lungs, and nervous system


Side Effects of Chemotherapy

Chemotherapy affects each person differently and the duration of side effects may vary from hours to months to years. Side effects can range in severity from unpleasant to life threatening (as in severe infection) and must be weighed against the need to treat the cancer. Common side effects include (ACS, 2020; NCI, 2015; Shapiro, 2021):                                                                                                                                                                                                              

Managing Side Effects of Chemotherapy
Side Effect Cause Patient Management/Treatment
  • Low red blood cell (RBC) production in the bone marrow
  • Provide rest between activities.
  • Encourage proper nutrition, for example foods high in protein and iron.
  • Erythropoietin-stimulating agents (ESAs) foster production of RBCs, but may increase risk for thromboembolism (Shapiro, 2021).
Appetite changes
  • Mouth and throat sores
  • Change in sense of taste or smell
  • Nausea and vomiting
  • Ensure adequate hydration.
  • Encourage a healthy, high-nutrient diet.
  • Promote exercise.
  • Treat oropharyngeal sores.
  • Provide adequate mouth care.
Bleeding and bruising
  • Thrombocytopenia
  • Avoid aspirin or ibuprofen.
  • Instruct patient to brush teeth gently with a soft toothbrush.
  • Avoid use of razors; use electric shaver.
  • Chemo and medications such as opioids
  • Changes in diet
  • Encourage high fiber foods.
  • Increase fluid intake.
  • Increase activity.
  • Administer stool softeners and/or laxatives as needed.
  • Appetite changes
  • Nausea and vomiting
  • Diarrhea
  • Increase fluid intake.
  • Intravenous (IV) fluids may be needed.
  • See measures to manage nausea, vomiting, and diarrhea below.
  • Chemo affects the smooth muscles in the GI tract (NCI, 2015)
  • Dietary modifications such as the BRAT diet; avoidance of milk, alcohol, and caffeine; avoidance of fatty, spicy and high fiber foods; eating smaller meals more frequently.
  • Antidiarrheal medication.
  • Increase fluid intake (8-12 cups per day).
  • Fluid build-up in the tissues due to chemotherapy or heart, liver, or kidney failure
  • Poor nutrition or blockage of veins or the lymph system
  • Avoid tight clothing and shoes; avoid crossing legs when sitting; compression stockings and sleeves may be needed.
  • Promote exercise.
  • Limit salt intake.
  • Consider diuretics for severe swelling.
  • Chemo-induced anemia and/or vasomotor symptoms that result in sleep difficulties and depression
  • Typically resolves when chemo is discontinued
  • Assess patient for causative factors such as anemia, pain, depression, hypoxia or fluid and electrolyte imbalances.
  • Provide rest between activities.
  • Discuss proper nutrition and encourage foods high in protein and iron.
Flu-like symptoms
  • Some types of chemo can cause flu-like symptoms within a few hours after treatment and may last for 2 to 3 days.
  • Encourage hydration for diarrhea and foods high in calories and protein for appetite loss.
  • Medicate for chills or body aches.
  • Contact provider before administering medication to lower a fever.
  • See treatment below for nausea and vomiting.
Hair loss
  • Some types of chemo cause hair to fall out
  • Hair thinning may begin after the second or third cycle of treatment
  • Treat hair gently: use a soft brush; avoid hair dryers, irons, gels, clips; use a mild shampoo and wash less frequently.
  • Protect the scalp with sunscreen or a hat when outside.
  • Reassure the patient that hair often grows back in 2 to 3 months after treatment has ended.
  • Suggest head wraps, hats, or wigs.
  • Scalp cooling devices used before, during and after treatment may reduce or prevent hair loss by restricting blood flow to the scalp and activity of hair follicles (ACS, 2019).
Hepatotoxicity (Shapiro, 2021)
  • Elevated bilirubin, alkaline phosphatase (ALK), aspartate transaminase (AST), and alanine transaminase (ALT) levels may result from chemotherapy.
  • Usually mild
  • Treatment may not be needed, instead adjust dose.
  • If severe, discontinue treatment.
  • Chemo may decrease white blood cell production leading to neutropenia which increases risk of infection (Shapiro, 2021).
  • Neutropenia may occur 10 to 14 days after each cycle and typically resolves prior to the next chemo treatment.
  • Monitor for signs of infection (fever, cough, sore throat, pain, rash, sores on mouth or tongue, swelling, redness).
  • Encourage good hand hygiene.
  • Avoid crowds, people who are sick and people that have recently received a live vaccine.
  • Encourage patients to use a mask when out in public.
  • Follow food safety guidelines.
Memory or concentration changes
  • Exact cause is unknown.
  • Symptoms include forgetfulness; difficulty concentrating; memory issues; trouble multi-tasking or remembering common words.
  • Exercise the brain with puzzles; encourage a class to learn something new.
  • Advise patient to get adequate rest and sleep.
  • Encourage physical activity.
  • Teach patient to follow a daily routine.
  • Encourage use of planners or smart phone applications to set reminders and stay organized.
Mouth and throat problems
  • Chemo may cause a chemical or metallic taste, a change in taste or smell, dry mouth, infections, mouth sores, pain/swelling, sensitivity to hot or cold, dysphagia, cavities, and mucositis (inflammation of the oral mucosa).
  • Low platelet count may cause bleeding in the mouth.
  • Tell patient to have a dental check-up and cleaning before treatment begins.
  • Promote good oral hygiene.
  • Swishing ice chips around mouth for 30 minutes may alleviate inflammation and sores (Shapiro, 2021).
  • Topical diphenhydramine, oral antacids and lidocaine may soothe symptoms (Shapiro, 2021).
Myalgias (muscle pain); arthralgias (joint pain)
  • Muscle and joint pain are associated with certain chemo drugs such as biologic therapies and growth factors.
  • Blood infections can cause muscle aches and fever.
  • Typically resolve when treatment is stopped.
  • Medications that may alleviate symptoms (Shapiro, 2021):
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Gabapentin
    • Glutamine
    • Antihistamines
Nausea and vomiting
  • Symptoms vary from mild, moderate, or severe depending on the regimen.
  • Administer antiemetics/anti-nausea medications as prescribed.
  • Tell patient to suck on ice, popsicles, or hard candy during chemo treatment.
  • Teach patient to increase fluid intake but avoid drinking with meals, and to avoid greasy, fried, sweet or spicy food.
  • Have patient sit up for 2 hours after eating.
  • Instruct patient to avoid strong odors, caffeine, and smoking during chemotherapy.
Peripheral neuropathy
  • Chemotherapy-induced peripheral neuropathy (CIPN) may cause nerve damage resulting in motor and sensory symptoms such as pain, numbness, weakness, burning, tingling, or unusual sensation in arms and legs (Shapiro, 2021).
  • Symptoms usually resolve after treatment is discontinued.
  • Duloxetine may be effective to treat chemotherapy-induced neuropathy (Shapiro, 2021).
Pulmonary toxicity
  • Some medications may cause pneumonitis which leads to dyspnea, cough, malaise, or fever.
  • Most symptoms resolve after treatment is discontinued.
  • Oxygen therapy may be needed.
  • Glucocorticoids may be used in severe cases (Shapiro, 2021).
Sexual health and fertility issues in men
  • Chemo may lower testosterone levels and libido.
  • Traces of chemo may be found in semen after treatment.
  • Chemo can damage sperm in men and germ cells in boys.
  • Discuss medications and procedures available to treat erectile dysfunction.
  • Advise patients to use condoms to prevent partner exposure to chemo in semen.
  • Refer to support groups or counseling.
  • Discuss fertility preservation options (sperm banking).
Sexual health and fertility issues in women
  • Chemo may lower estrogen levels and affect ovarian function causing hot flashes, irregular or no periods, and vaginal dryness that can cause painful intercourse.
  • Chemo may affect vaginal tissue and cause sores.
  • Chemo can stop ovaries from releasing eggs and estrogen or lower the number of eggs in the ovaries.
  • Discuss medications to decrease pain during intercourse (i.e, vaginal gels, creams, lubricants).
  • Teach patient to perform Kegel pelvic muscle exercises.
  • Advise patients to use condoms to prevent partner exposure to chemo in vaginal fluids.
  • Refer to support groups or counseling.
  • Non-estrogen treatments: gabapentin, selective serotonin reuptake inhibitors (SSRI) and selective serotonin norepinephrine reuptake inhibitors (SSNRIs) (Shapiro, 2021).
  • Discuss fertility preservation options (egg or embryo cryopreservation).
Skin and nail changes
  • Due to chemo; very common
  • The cause is unknown but there may be a toxic or allergic basis.
  • The severity and duration of allergic skin reactions may be independent of dose and may persist after the drug has been discontinued.
  • For dry, itchy, red skin, tell patient to:
    • Use mild soap, lotions, and creams.
    • Avoid products with alcohol or perfume.
    • Apply lotion after bathing.
    • Avoid hot water.
    • Keep home cool and humid.
  • For rash, instruct patient to seek medical attention immediately to rule out an allergic reaction.
  • Administer anti-itch medications as needed.
  • Tell patient to always use sunscreen when outdoors due to increased susceptibility to sunburn.
  • For discolored, cracked, brittle nails, teach patient to keep nails clean and trimmed, and wear protective gloves for gardening and house cleaning.
Urinary and bladder problems
  • Chemo may affect or damage the bladder and kidneys.
  • Chemo can cause a change in the color or smell of urine.
  • Monitor for signs of urinary tract infection: pain, burning on urination, red or cloudy urine, fever, back or abdominal pain, inability to urinate.
  • Encourage patient to drink a minimum of 8 cups of fluid each day and avoid caffeine, alcohol, and tobacco.
Weight gain
  • Chemo may induce hormonal changes and alter adipose tissue causing insulin resistance (Shapiro, 2021).
  • Chemo-related edema may increase weight.
  • Encourage a proper diet and physical activity.
  • Teach patient to avoid salt intake and high-calorie foods.
  • Refer to a nutritionist, as indicated.
Weight loss
(ACS, 2019)
  • Poor appetite
  • Mouth sores, bleeding
  • Dysphagia
  • Change in sense of taste, smell
  • Diarrhea
  • Vomiting
  • Dehydration
  • Encourage high-calorie and high-protein foods including snacks.
  • Recommend liquid food supplements.
  • Ensure adequate hydration.
  • Administer antiemetics and antidiarrheals as needed.
  • Refer to a nutritionist, as indicated.

American Cancer Society (ACS). (2020, May 1). Chemotherapy side effects.

American Cancer Society (ACS). (2019). Managing Cancer-related side effects.

National Cancer Institute (NCI). (2015, April 15). Chemotherapy to treat cancer.

National Cancer Institute (NCI) (2018). Side Effects of Cancer Treatment.

Shapiro, C. L. (2021, December 16). Acute side effects of adjuvant chemotherapy for early-stage breast cancer. UpToDate.