Although chemotherapy is given to kill cancer cells, it also can damage normal cells. The normal cells most likely to be damaged are those that divide rapidly:

• bone marrow/blood cells
• cells of hair follicles
• cells lining the reproductive and digestive tracts

Damage to these cells accounts for many of the side effects of chemotherapy drugs. Side effects are different for each chemotherapy drug, and they also differ based on the dosage, the route the drug is given, and how the drug affects you individually.

If after reading this section you want more information about managing the side effects of chemotherapy, please call the American Cancer Society at 1-800-ACS-2345 and ask for the booklet "Understanding Chemotherapy: A Guide for Patients and their Families."

Bone Marrow Suppression

The bone marrow is the thick liquid in the inner part of some bones that produces white blood cells (WBCs), red blood cells (RBCs), and blood platelets. Damage to the bone marrow is called bone marrow suppression, or myelosuppression, and is one of the most common side effects of chemotherapy.

Cells are constantly produced in the bone marrow where they are growing rapidly and, as a result, are sensitive to the effects of chemotherapy. Until your bone marrow cells recover from chemotherapy damage, you may have abnormally low numbers of WBCs, RBCs, and/or platelets.

While you are getting chemotherapy your blood will be tested regularly, even daily when necessary, so the numbers of these cells can be counted. This test is often called a complete blood count (CBC). Bone marrow samples may also be taken periodically to check on the blood-forming marrow cells that develop into WBCs, RBCs, and platelets.

The decrease in blood cell counts does not occur right at the start of chemotherapy because the drugs do not destroy the cells already in the bloodstream (these are not dividing rapidly). Instead, the drugs affect the formation of new blood cells by the bone marrow.

As blood cells normally wear out, they are constantly replaced by the bone marrow. Following chemotherapy, as these cells wear out, they are not replaced as they would be normally, and the blood cell levels will begin to drop. The type and dose of the chemotherapy will influence how low the blood cell counts will drop and how long it will take for the drop to occur.

Each type of blood cell has a different life span:

• WBCs cells live for an average of 6 hours
• platelets average 10 days
• RBCs average 120 days

The lowest count that blood cell levels fall to is called the nadir. The nadir for each blood cell type will occur at different times, but usually WBCs and platelets will reach their nadir within 7 to 14 days. Because RBCs live longer, they will typically not reach a nadir for several weeks. Within 3 or 4 weeks, the nadir usually resolves and counts approach normal levels.

Knowing what these 3 types of blood cells normally do can help you understand the effects of low blood cell counts.

• WBCs help the body fight off infections.
• Platelets help prevent bleeding by forming plugs to seal up damaged blood vessels.
• RBCs bring oxygen to cells throughout the body so they can turn certain nutrients into energy.

The side effects caused by low blood cell counts will likely be at their worst when the WBC, RBC, and platelets are at their nadirs or lowest values.

Low white blood cell counts: The medical term for a low WBC count is leukopenia. Blood normally has between 4,000 and 10,000 WBCs per cubic millimeter. WBCs are divided into 2 main categories, based on how they appear under the microscope:

• granulocytes, which contain granules (visible specks) in the cytoplasm of the cell. This category includes 3 subtypes -- neutrophils, eosinophils, and basophils.

• agranulocytes, which do not contain granules in the cytoplasm of the cell. This category includes 3 subtypes -- lymphocytes, monocytes, and macrophages.

Granulocytes, especially neutrophils, provide an important defense against infections and are the most numerous type of WBC. Neutropenia, an abnormally low number of neutrophils, is the most common factor that puts people with cancer at risk for infection. The normal range of neutrophils is between 2,500 and 6,000 cells per cubic millimeter. Your doctor will likely watch your neutrophil count closely during chemotherapy.

To determine how likely someone is to develop an infection, health care providers look at the number of neutrophils in the blood, called the absolute neutrophil count (ANC). Someone with an ANC of 1,000 or less is neutropenic and at risk of developing an infection. An ANC lower than 500 is considered severe neutropenia.

Having a low WBC count or neutrophil count does not mean you will definitely have an infection. But you need to watch for these signs and symptoms:

• fever
• sore throat
• new cough or shortness of breath
• nasal congestion
• burning during urination
• shaking chills
• redness, swelling, pain, and warmth at the site of an injury or at an IV or implanted catheter site

Fever is a very important sign and may be the first sign of an infection. Usually you will be instructed to call your doctor or nurse if you have a fever higher than or equal to 100.5º F, any signs or symptoms of infection, or shaking chills.

Your health care team may take measures to lower your risk of infection. You may be instructed to stay away from small children or other people who are likely to be sick. When WBC counts are very low, doctors often prescribe antibiotics as a preventive measure. These anti-infection drugs may be given intravenously or by mouth.

Because of the risk of infections, further chemotherapy doses may need to be delayed when you have a very low WBC count.

In some situations, doctors may prescribe growth factors to keep the WBCs from falling too low so that chemotherapy can be given on schedule. (As previously discussed, the timing of the chemotherapy cycle is important in getting maximum cancer cell kill.) Your body normally produces several growth factors (also called colony-stimulating factors) to prompt the bone marrow to make various types of blood cells. But the normal levels of these factors in the body are often not enough to keep up with demands during chemotherapy. Researchers have learned how to make these growth factors in the lab, and they are now available as drugs which help the body maintain normal blood cell levels.

The growth factors that stimulate production of WBCs are granulocyte-macrophage colony-stimulating factor (GM-CSF, also called sargramostim or Leukine) and granulocyte colony-stimulating factor (G-CSF, also called filgrastim or Neupogen). These drugs are often given daily, usually starting the day after you receive chemotherapy. They can be given for up to 2 weeks. A newer, longer lasting form of G-CSF (pegfilgrastim or Neulasta) is now available and is given only once each chemotherapy cycle, usually 24 hours after completing chemotherapy.

These drugs help bone marrow recover more quickly and reduce your risk of getting a serious infection. They are commonly given as injections under the skin (SQ). Nurses give the injections if you are in the hospital or at the doctor’s office, but you or your family members can learn how to give these injections at home.

Low red blood cell counts: Not having enough RBCs is called anemia. Doctors use 2 measurements to determine if you have enough RBCs.

• The red pigment in RBCs that carries oxygen is hemoglobin. If there are not enough RBCs, the blood hemoglobin concentration will be less than its usual range of 12 to 16 grams per deciliter (g/dL) in women or 14 to 18 g/dL in men.

• Hematocrit is the percentage of total blood volume occupied by RBCs. Its normal range is between 37% and 52%. Levels are normally higher for men than for women.

With anemia, you may have the following symptoms:

• fatigue (described below)
• pallor or paleness
• dizziness
• headaches
• irritability
• shortness of breath
• low blood pressure
• an rise in heart rate or breathing rate (or both)

Anemia caused by chemotherapy is usually temporary. But blood loss caused by surgery or by the cancer (a common occurrence with colorectal cancers, for example) can make anemia even worse.

If the symptoms are severe, blood transfusions can temporarily correct the RBC levels until the bone marrow is healthy enough to replace worn-out RBCs. Because blood transfusions have some risks, doctors use this procedure only if there are serious signs and symptoms, such as severe shortness of breath and/or very low RBC counts (typically less than 8 g/dL). Other factors will also affect this decision. For example, people with heart or lung diseases are more sensitive to anemia and may have severe symptoms even though their hemoglobin levels may be higher than 8 g/dL.

An option for treating anemia caused by chemotherapy is a drug called epoetin (also called EPO, Procrit, or Epogen). This drug is a manmade version of a naturally occurring growth factor that prompts bone marrow cells to make more RBCs. It can relieve symptoms of anemia and reduce the need for blood transfusions, but it may take 2 to 8 weeks to work. Epoetin is generally given once a week by injection under the skin (SQ) until the hemoglobin level rises to an acceptable level (usually greater than 12 g/dL). A newer, longer lasting form, known as darbepoetin (Aranesp), may only need to be given every 2 to 3 weeks.

Low platelet counts: The normal range for platelet counts is between 150,000 and 450,000 per cubic millimeter. The medical term for a low platelet count is thrombocytopenia.

If your platelet count is low, you may show these signs:

• bruise easily
• bleed longer than usual after minor cuts or scrapes
• have bleeding gums or nose bleeds
• develop petechiae (small reddish purple spots on the skin)
• have headaches
• have visible blood in stool or urine
• have serious internal bleeding if the platelet count is very low

Although low platelet counts resulting from chemotherapy are temporary, they can cause serious blood loss. This, in turn, can lead to damage in internal organs.

Sometimes a low platelet count will delay necessary surgery because doctors are concerned about blood loss during surgery.

If platelet counts are very low (below 10,000) or if a person with moderately low counts has greater than normal bleeding or bruising, platelet transfusions may be given. Transfused platelets last only a few days and must often be repeatedly given. Some people who have received many platelet transfusions can develop an immune reaction that destroys donor platelets.

A platelet growth factor called oprelvekin (Neumega) is a drug that can be given to people with severe thrombocytopenia. This lowers their need for platelet transfusions and can lessen the risk of bleeding. The drug is given as an injection under the skin (SQ) every day.

Nausea and Vomiting

Many patients getting chemotherapy worry about nausea and vomiting more than any other side effects. New medicines can help prevent or treat nausea and vomiting, making it less prevalent than in the past, but it is still a possible effect of chemotherapy. Chemotherapy agents cause nausea and vomiting for a variety of reasons. One reason is they irritate the lining of the stomach and duodenum (the first section of the small intestine). This stimulates certain nerves that activate the vomiting center (VC) and the chemoreceptor trigger zone (CTZ) in the brain which leads to vomiting. Another way these areas of the brain can be activated is through obstruction, delayed gastric emptying, or inflammation -- all possible effects of chemotherapy.

Nausea is an unpleasant wavelike sensation in the stomach and back of throat. It can be accompanied by symptoms such as sweating, light-headedness, dizziness, increased salivation, and weakness. It can lead to retching, vomiting, or both.

Retching is a rhythmic movement of the diaphragm and stomach muscles that are controlled by the vomiting center.

Vomiting is a process controlled by the vomiting center that causes the contents of the stomach to be forced out through the mouth. Vomiting can occur at various times. It can be acute, occurring within minutes to hours after chemotherapy, or delayed, developing or continuing for 24 hours after chemotherapy and sometimes lasting for days.

Anticipatory vomiting occurs when you have had a bad experience with nausea and vomiting in the past that was not treated. This conditioned response can be stimulated by sights, sounds, or odors. As a result, you develop nausea and vomiting when placed in the same situation (for example, before receiving the next chemotherapy treatment).

Although it is not possible to predict the onset, severity, or duration of nausea and vomiting for any one person, certain chemotherapy drugs are more likely to cause nausea and vomiting. Some examples of these are:

• cisplatin
• dacarbazine
• mechlorethamine
• melphalan
• daunorubicin
• cytarabine (high doses)
• streptozocin
• carmustine
• etoposide (high doses)
• cyclophosphamide
• procarbazine
• lomustine
• dactinomycin

Other factors that may affect the amount and severity of nausea and vomiting include:

• prior experiences with motion sickness
• previous bad experience with nausea and vomiting
• fatigue
• anxiety during treatment
• heavy alcohol intake (currently or in the past)
• being a woman of menstrual age (at greatest risk for severe and long-lasting nausea and vomiting)

The key to effective control of nausea and vomiting is to prevent it before it occurs whenever possible. Many drugs are used alone or in combination to prevent or decrease nausea and vomiting. They include:

• lorazepam
• prochlorperazine
• promethazine
• metoclopramide
• dexamethasone
• ondansetron
• granisetron
• dolasetron
• palonosteron
• aprepitant

Consideration may also be given to non-drug methods to help with nausea and vomiting, such as:

• ginger in tablets or in ginger ale
• relaxation exercises
• guided imagery
• soothing music

Hair Loss

Some chemotherapy drugs affect the rapidly growing cells of hair follicles. Your hair may become brittle and break off at the surface of the scalp, or it may simply fall out from the hair follicle. The medical term for hair loss is alopecia. While it is certainly not a life-threatening event, it does have a social and psychological impact on some people and patients and their families should be prepared for it.

Basic facts about hair loss:

• Whether or not hair loss occurs depends on which drugs are given, their doses, and the length of treatment. Hair loss can be very individual. Some people may have complete loss of hair while others may see just a thinning of their hair. Loss of eyebrows, eyelashes, pubic hair, and body hair is usually less severe because the growth is less active in these hair follicles than in the scalp.

• If hair is going to be affected, you may see "shedding" start 2 to 3 weeks after treatment begins.

• Hair loss from chemotherapy is almost always temporary. When your hair grows back, its color or texture may be different. Hair may start to grow again near the end of your treatment or after the treatment is completed.

• Unlike some other side effects of chemotherapy, hair loss is never life threatening. But it may have a substantial impact on your quality of life. Hair loss may cause depression, loss of self-confidence, and grief reactions.

Appetite Loss and Weight Changes

Most chemotherapy medicines cause some degree of anorexia, a decrease in or complete loss of appetite. Loss of appetite, as well as weight loss, may also result directly from effects of the cancer on the body’s metabolism.

Anorexia may be mild, or, if severe, it may lead to cachexia, a form of malnutrition with muscle wasting. Proper nutrition helps strengthen the body to fight the disease and infection and also cope with cancer treatments.

Decreased appetite is generally temporary and returns when chemotherapy is finished. It may take a few weeks after chemotherapy is finished for your appetite to recover. Some chemotherapy may cause more severe loss of appetite.

Talk with your doctor or nurse if you experience anorexia or cachexia. Medicines can be prescribed to help improve these conditions.

Weight loss can be a result of appetite loss, vomiting, diarrhea, and drug side effects. Sometimes people gain weight during cancer treatment. This can be caused by chemotherapy regimens containing steroids, inactivity, electrolyte imbalances, and fluid retention.

Your weight will be monitored during your cancer treatment and a dietician and/or nutritionist may be consulted to help you learn ways to maintain an appropriate body weight.

Taste Changes

Cancer treatments and the cancer itself can change the way some food tastes. Taste changes can contribute to anorexia and malnutrition and weight changes. With taste changes caused by chemotherapy, you may notice:

• either a dislike for or an increased desire for sweet foods
• dislike of foods with bitter tastes
• dislike for tomatoes and tomato products
• dislike for beef or pork
• constant metallic or medicinal taste in your mouth

These changes occur because chemotherapy drugs can change the taste receptor cells in your mouth that tell you what flavor you are tasting. Nutritional deficits, oral hygiene, mouth infections, dentures, and unpleasant odors can also affect your ability to taste. Changes in taste and smell may continue as long as chemotherapy treatments continue, or even longer. Several weeks after chemotherapy has ended, taste and smell sensations usually (but not always) return to normal.

Sores in the Mouth or Throat

Some chemotherapy drugs can cause sores to develop in the mouth or throat. These drugs affect the rapidly dividing cells that line these areas, making them unable to adequately replace normal cell loss.

Stomatitis refers to the inflammation and sores within your mouth that may result from chemotherapy. Similar changes in the throat are called pharyngitis and in the esophagus (the tube that leads from the throat to the stomach) are called esophagitis. The term mucositis is used to refer to inflammation of the mucous membrane layer lining the entire digestive (gastrointestinal) tract, from the mouth to the rectum, and the vagina.

The first signs of mouth sores occur when the lining of the mouth appears pale and dry. Later, the mouth, gums, and throat may feel sore and become red and inflamed. The tongue may be "coated" and swollen, leading to trouble swallowing, eating, or talking. Stomatitis, pharyngitis, and esophagitis can lead to bleeding, painful ulcers, and infection.

Mouth, throat, and esophagus sores are temporary and usually develop 5 to 14 days after receiving chemotherapy. Stomatitis gradually reverses itself within 2 to 3 weeks and will heal completely once chemotherapy is finished.

Constipation

Constipation is the passage (usually with discomfort) of infrequent, hard, dry stool. If you have constipation, you may also notice bloating, increased gas, cramping, or pain. Constipation affects about half of people with cancer and about 3 out of 4 of those with advanced disease.

Risk factors for developing constipation include:

• taking opioid pain medicines
• lack of physical activity
• low fiber diet and decreased intake of food
• decreased fluid intake and dehydration
• bed rest
• depression
• getting certain chemotherapy drugs (such as vincristine and vinblastine)

If constipation develops, your doctor will try to determine the cause then take appropriate measures to treat the problem. Be aware of your bowel patterns, try to stay active, try to eat high fiber foods, and try to drink at least 3000 mls of fluid each day. Tell your doctor if you go more than three days without a bowel movement. "Understanding Chemotherapy: A Guide for Patients and their Families."

Diarrhea

Diarrhea is the passage of increased volume of loose or watery stools several times a day with or without discomfort. Along with diarrhea, you may have gas, cramping, and bloating. Diarrhea occurs in about 3 out of 4 people who receive chemotherapy because of the damage to the rapidly dividing cells in the digestive (gastrointestinal) tract.

Factors affecting diarrhea during chemotherapy:

• receiving drugs that cause diarrhea (examples include irinotecan, 5-fluorouracil, methotrexate, docetaxel, doxorubicin, and dactinomycin)
• drug dose
• length of treatment
• having a stomach tumor
• intestinal bacteria or viruses
• medications such as antibiotics or antacids
• nutritional supplements
• receiving both radiation and chemotherapy
• food allergies or being lactose intolerant (can’t drink milk, for example)
• lifestyle changes, stress, and anxiety

Diarrhea can be serious and become life threatening if it leads to dehydration, malnutrition, and electrolyte imbalances. It is important to report any diarrhea to your doctor or nurse so that it can be treated promptly. Keep a record of the number of times you have diarrhea, the amount, and the appearance and give this information to your doctor.

Fatigue

Fatigue is one of the most common side effects of cancer and chemotherapy. It can be one of the most debilitating side effects people experience. With fatigue caused by chemotherapy, you may experience these feelings:

• weariness
• weakness
• lack of energy
• decreased ability for physical and mental work
• trouble thinking and concentrating
• forgetfulness

The fatigue a person with cancer feels is different from the fatigue of everyday life. It is unrelated to activity and may not be resolved with rest or sleep. Fatigue can be prolonged and can affect health and your quality of life. Discuss your fatigue with your health care team. They can correct any physical causes (such as anemia) and help you manage it through self-care activities and coping strategies.

Heart Damage

Certain chemotherapy drugs can damage the heart. The most common ones are the anthracyclines, such as daunorubicin and doxorubicin, but other drugs may cause it as well. This occurs in about 1 in 10 people who receive these drugs and usually involves damage to the heart muscles.

If the heart is damaged by chemotherapy, it may not be able to pump blood through the body as well as it did before treatment. This can lead to fluid buildup and other problems. You may feel these symptoms:

• puffiness or swelling in the hands and feet
• shortness of breath
• dizziness
• erratic heartbeat
• dry cough

If you have had previous radiation to the mid-chest area before, pre-existing heart problems, uncontrolled high blood pressure, or are a smoker, you will be at higher risk for heart damage.

Before chemotherapy is started, your doctor will check your heart function to make sure that there are no major problems. Your heart function will also be checked during treatment to ensure that no changes have occurred. Tests such as an electrocardiogram (EKG), an echocardiogram, or a MUGA scan are done to check for any changes in heart function. An echocardiogram is an ultrasound of the heart. With a MUGA scan, you receive a radioactive substance that is then traced through your heart with a special scanner.

If problems develop, the chemotherapy drug will be stopped to prevent further permanent damage. Tell your doctor or nurse right away if you notice changes in your heart rhythm, shortness of breath, weight gain, or fluid retention.

Nervous System Changes

Some chemotherapy drugs can cause direct or indirect changes in the central nervous system (brain and spinal cord), the cranial nerves, or peripheral nerves. The cranial nerves are connected directly to the brain and are important for movement and touch sensation of the head, face, and neck. Cranial nerves are also important for vision, hearing, taste, and smell. Peripheral nerves lead to and from the rest of the body and are important in movement, touch sensation, and regulating activities of some internal organs.

Side effects that are the result of nerve damage caused by chemotherapy can occur soon after chemotherapy starts or years later.

Changes in the central nervous system could produce these symptoms:

• stiff neck
• headache
• nausea and vomiting
• lethargy or sleepiness
• fever
• confusion
• depression
• seizures

Damage to the cranial nerves may cause these symptoms:

• visual problems (such as blurred vision or double vision)
• increased sensitivity to odors
• hearing loss or ringing in the ears
• dry mouth

Peripheral nervous system changes usually affect the hands and feet and can include:

• numbness
• tingling
• decreased sensation

These may make you feel clumsy and cause difficulty in daily activities such as opening jars, fastening buttons, or squeezing toothpaste tubes.

Some of the most commonly used drugs that cause peripheral nerve damage include the mitotic inhibitors (vincristine, paclitaxel, docetaxel, etc.) and cisplatin. Nerves can heal and if the chemotherapy dose is lowered or treatment is stopped, the symptoms will usually decrease or disappear. However, there are times when the damage may be permanent. For this reason it is important that you report any changes to your healthcare team as soon as possible.

Changes in Thinking and Memory

Recent research has shown that chemotherapy can also affect the way your brain functions, even many years after treatment. This occurs in a small number of patients and is often worse in people who received larger doses of chemotherapy. Some of the brain’s activities that are affected are concentration, memory, comprehension (understanding), and reasoning.

The changes that have been found in patients are subtle, but the people who have problems are well aware of the differences in their thinking. Patients who have had chemotherapy and have this cognitive impairment often call this experience "chemo brain" or "chemo-fog.” Researchers are not sure exactly why chemotherapy affects the brain in this way or exactly how much chemotherapy (or in what combinations) it takes to cause this problem.

Researchers are currently studying the problem to get more information to help prevent and treat cognitive impairment for chemotherapy patients. If you have problems with thinking that interfere with daily life, there are programs that can help you improve your memory and problem-solving abilities. Simply being aware that problems with thinking can occur may help patients and their family members feel less isolated and alone.

Lung Damage

It is possible for some chemotherapy drugs, such as bleomycin, to cause irreversible damage to the lungs. The chance of this occurring is higher if you receive radiation to the chest along with chemotherapy. Age also seems to be an important factor in the development of lung damage. For example, people over 70 years old have about three times the risk of developing lung problems from the drug bleomycin.

Lung damage may cause symptoms such as shortness of breath, a nonproductive (dry) cough, and possibly fever. If the chemotherapy drug is stopped early enough, the lung tissue can regenerate. Because early lung changes may not show up on a chest x-ray, your doctor may assess your lungs through pulmonary function tests and arterial blood gas tests. Lung damage can be permanent. Discuss any breathing changes you may notice with your healthcare team.

Reproduction and Sexuality

Reproductive and sexual problems can occur after you receive chemotherapy. Which, if any, problems develop depends on your age when you are treated, the dose and duration of the chemotherapy, and which chemotherapy drug(s) are given.

Sexual changes men may experience:

• Most men on chemotherapy still have normal erections. A few, however, may develop problems. Erections and sexual desire often decrease just after a course of chemotherapy, but usually recover in a week or two. A few chemotherapy drugs, for example, cisplatin or vincristine, can permanently damage parts of the nervous system. Although it is not yet proven, these drugs may interfere with the nerves that control erection.

• Chemotherapy can sometimes affect sexual desire and erections by slowing down the amount of testosterone produced. Some of the medications used to prevent nausea during chemotherapy can also upset a man's hormonal balance, but hormone levels should return to normal after treatments have ended.

• Many chemotherapy drugs can affect sperm and the parts of the body that produce them. Some of these effects may be permanent. Freezing sperm prior to chemotherapy is one option for men who wish to father children later in life. Although it is possible to conceive during chemotherapy, the toxicity of some drugs may cause birth defects. Therefore, it is suggested that all men getting chemotherapy take precautions and use a reliable type of birth control if they are sexually active.

• Chemotherapy may suppress your immune system. If you have had genital herpes or genital wart infections in the past, you may have flare-ups during chemotherapy.

• Chemotherapy is often given through an IV tube into the bloodstream. However, new ways have been developed to bring drugs directly to a tumor. For cancer of the bladder, for example, a liquid is placed directly into the bladder through a catheter in the urethra. Such a treatment has only a minor effect on a man's sex life. You may notice some pain if you have intercourse too soon after the treatment. This is because the bladder and urethra are still irritated.

For more information, please see the American Cancer Society document, "Sexuality & Cancer: For the Man Who Has Cancer and His Partner."

Sexual changes women may experience:

• Many chemotherapy drugs can either temporarily or permanently damage a woman’s ovaries, reducing their output of hormones. This affects a woman's fertility and libido. Ovarian function is less likely to return in women over age 30 and they are, therefore, more likely to go into menopause. Symptoms of early menopause include hot flashes, vaginal dryness and tightness during intercourse, and irregular or no menstrual periods. As the lining of the vagina thins, light spotting of blood after intercourse becomes common. Even though menstrual cycles may be disrupted or stopped with chemotherapy, it may still be possible to get pregnant at this time. The toxicity of some chemotherapy drugs may cause birth defects and it is suggested that all women getting chemotherapy take precautions and use a reliable type of birth control if they are sexually active.

• Some chemotherapy drugs irritate all mucous membranes in the body. This includes the lining of the vagina, which often becomes dry and inflamed (a condition called vaginitis).

• Vaginal infections are common during chemotherapy, particularly in women taking steroids or the powerful antibiotics used to prevent bacterial infections. Yeast cells are a natural part of the vagina's cleansing system. If too many grow, however, you may notice itching inside your vagina, a whitish discharge that often looks like cottage cheese, or a burning sensation during sexual intercourse. Yeast infections can often be prevented by not wearing pantyhose, nylon panties, and tight pants. Loose clothing and cotton panties allow better air circulation. Your doctor may also prescribe a vaginal cream or suppository to reduce yeast cells or other organisms that grow in the vagina. It is very important to have a vaginal infection treated if you are taking chemotherapy. Your body's immune system is not as strong because of the treatment, and any infection may become a more serious problem if it is not dealt with as early as possible.

• If you have had genital herpes or genital wart infections in the past, you may have flare-ups during chemotherapy. This is because the chemotherapy suppresses your immune system.

• Chemotherapy is often given through an IV tube into the bloodstream. However, new ways have been developed to bring drugs directly to a tumor. For cancer of the bladder, for example, a liquid is placed directly into the bladder through a catheter in the urethra. Such a treatment has only a minor effect on a woman's sex life. You may notice some pain if you have intercourse too soon after the treatment. This is because the bladder and urethra are still irritated.

For more information, please see the American Cancer Society document, "Sexuality & Cancer: For the Woman Who Has Cancer and Her Partner."

Liver Damage

The liver is the organ that breaks down (metabolizes) most of the chemotherapy drugs that enter the body. Unfortunately, some drugs can cause liver damage, including methotrexate, cytarabine (ara-C), vincristine, and streptozocin. Most often the damage is temporary, and the liver recovers a few weeks after the drug is stopped.

Signs of liver damage include:

• yellowing of the skin and the whites of the eyes (jaundice)
• fatigue
• pain under the lower part of the right ribs on the right side
• swelling of the abdomen or in the feet

Blood tests may be needed to watch for possible liver damage. People who are older or who have hepatitis may be more likely to develop liver damage.

Kidney and Urinary System Damage

Many of the breakdown products of chemotherapy drugs are excreted through the kidneys. These drug byproducts can damage the kidneys, ureters, and bladder. If you have a history of kidney problems, you may be at a higher risk for kidney damage.

Certain chemotherapy drugs such as cisplatin, high-dose methotrexate, ifosfamide, and streptozocin are more likely to cause kidney and urinary damage than other medications.

Signs of possible kidney problems:

• headache
• pain in the lower back
• fatigue
• weakness
• nausea
• vomiting
• high blood pressure
• increased breathing rate
• change in how often you urinate
• change in color of urine
• swelling or puffiness of the body

Blood tests to measure kidney function are done regularly to watch for any changes.

Long-term Side Effects of Chemotherapy

For many people with cancer, chemotherapy is the best option for controlling their disease. You may be faced, however, with long-term side effects related to your chemotherapy treatments.

In some cases, side effects related to specific chemotherapy drugs can continue after the treatment is completed. These effects can progress and become chronic, or new side effects may develop. Long-term side effects depend on the specific drugs received and whether you received other treatments such as radiation therapy.

• Permanent organ damage: Certain chemotherapy drugs may permanently damage the body’s organs. If the damage is detected during treatment, the drug will be stopped. However, some of the side effects may remain. Damage to some organs and systems, such as the reproductive system, may not show up until after chemotherapy is finished.

• Delayed development in children: When young children receive chemotherapy for cancer treatment, it may affect their growth and their ability to learn. Several factors affect long-term side effects, including the age of the child, the specific drugs that are given, the dosage and length of treatment, and if chemotherapy is used along with other types of treatment such as radiation.

• Nerve damage: Nervous system changes can develop months or years after treatment with some drugs. Signs of nerve damage may include hearing loss or tinnitus (ringing in the ears), changes in sensations in the hands and feet, personality changes, sleepiness, impaired memory, shortened attention span, and seizures.

• Blood in the urine: Hemorrhagic cystitis (blood in the urine), a side effect of cyclophosphamide and ifosfamide, can continue for some time and even worsen after the drug is stopped. Treatment is available.

• Another cancer: Development of a second cancer is a great concern for cancer survivors. Some chemotherapy drugs raise the risk of developing another type of cancer later on. This risk is affected by many factors, including the age of the patient and whether or not other treatments like radiation were used. The most commonly reported secondary cancers are leukemias, lymphomas, and some solid tumors. Routine follow-up care after treatment is finished is an essential component of cancer care for all cancer survivors.

Revised: 11/17/2006

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