Tiredness
Tiredness (fatigue) is a common side-effect. Try to anticipate that you will feel more tired during a course of chemotherapy. You may need to cut back on your normal activities, plan regular rests, and if possible, take some regular light exercise. Some people feel overwhelmingly tired and may need to rely on other people to do routine daily chores.

Nausea and vomiting
It is common to feel sick (nausea) during and after each cycle of treatment. Try to drink plenty of fluids even if you do not feel like it, to prevent dehydration. Sucking ice cubes is one tip to increase your fluid intake.

Anti-sickness medication will usually help and is commonly taken at the same time as, or just before, a cycle of chemotherapy. There are different types of anti-sickness medication. If one does not work so well, a change to a different one may work better. Anti-sickness suppositories are also an option. Suppositories are tablets which you insert into the the rectum (back passage) and are absorbed into the bloodstream from there.

Effects on the blood and immune system
Cytotoxic drugs can affect the bone marrow. The bone marrow is where you make red blood cells, white blood cells and platelets. Problems which may occur include:

• Anaemia. This means a low level of red blood cells. If you develop anaemia you will feel tired and look pale. You may need a blood transfusion.
• Serious infection. You are more prone to infection if the level of white blood cells goes down. (You have less ability to fight off bacteria, viruses and other germs.) See a doctor straight away if you develop signs of infection such as fever or a sore throat. As you have a reduced capacity to fight infection you may be given a high dose of antibiotics directly into your bloodstream if you develop an infection.
• Bleeding problems. Platelets help the blood to clot when we cut ourselves. If the number of platelets in your blood goes down you may bruise easily and bleed for longer than usual after cuts. See a doctor urgently if you notice these symptoms. You may require a platelet transfusion if your platelet level goes very low.

Prior to each cycle of treatment, it is usual to have a blood test to check on your 'blood count'. This checks the level of your red blood cells, white blood cells and platelets. If any of these are too low, then a treatment cycle may be delayed, the choice of drugs may be altered, or you may be given treatment to boost the levels of these blood constituents.

Mouth problems
The cells which line the mouth are affected by some cytotoxic drugs. This may lead to a sore mouth, a dry mouth, or other mouth problems. Tell you doctor if you notice any problems in your mouth or throat. Routine good mouth care will help to prevent mouth problems from developing, or from becoming more serious. If possible, do the following either yourself or with the help of a carer.

• Brush your teeth twice a day with a soft toothbrush and fluoride-containing toothpaste.
• Rinse your mouth after meals and at night. Use water or 0.9% sodium chloride solution (saline or salt water). You can make a fresh sodium chloride solution for each rinse by dissolving half a teaspoon of salt in 250 ml fresh water. Use cool or warm water, whatever your prefer.
• Remove any debris that you can see in your mouth or on your tongue by gentle brushing with a soft toothbrush. If possible, do this regularly but mainly after meals and at bedtime. Foam sticks are an alternative if brushing with a soft toothbrush causes pain or bleeding.
• Chewing pineapple may also help to clean your mouth. Pineapple contains ananase which is an enzyme (chemical) that can help to break down debris in the mouth. You can use fresh pineapple or unsweetened tinned pineapple.
• Remove dentures at night. Clean dentures with a soft toothbrush and toothpaste. Soak overnight in a denture solution containing sodium hypochlorite. Rinse before use the next day. (Soak metal dentures in chlorhexidine solution.)

If you develop a dry mouth then simple measures such as frequent sips of water and chewing sugar-free gum will often help and be all that is needed in many cases. Artificial saliva or medication to stimulate the salivary glands are sometimes used. (There are separate leaflets called 'Mouth Care' and 'Dry Mouth' which give more details.)

Hair loss
Some cytotoxic drugs damage the hair making cells. Some or all of your hair may fall out. This usually occurs 2-3 weeks after a course of treatment starts. Body hair and eyelashes may also fall out in addition to scalp hair. After the course of treatment has finished the hair will usually regrow within 4-12 months.

Hair loss does not bother some people. You may wish to cut your hair short before starting chemotherapy so that any changes are not so dramatic. Some people like to wear a wig. Other people prefer to wear a hat or scarf. In particular, remember to cover your head or wear high protection sun screen when out in the sun. If your eyelashes fall out, you can wear glasses or sunglasses to protect your eyes on windy days.

Constipation
This may be helped by eating plenty of foods high in fibre, and having lots to drink. A laxative may be needed in some cases.

Diarrhoea
This is a side-effect from some drugs. You should increase the amount that you drink if you develop diarrhoea. If it persists or becomes severe, you should tell your doctor. Anti-diarrhoea medicines may be needed, and you may even need to be admitted to hospital for a 'drip of fluid' if you become dehydrated due to severe diarrhoea.

Nerve problems
Some drugs can affect nerves. This may lead to lack of sensation in parts of the body such as the fingers or toes, pins and needles, or weakness of muscles. Tell your doctor if any of these symptoms occur.

Fertility
Some chemotherapy drugs can affect fertility in both men and women. Sometimes this is temporary, and sometimes it is permanent. If this is a concern, one option may be for men to store sperm or women to store ova (eggs) before chemotherapy treatment begins. These can be 'frozen' and may be able to be used in the future if you wish to have a pregnancy.

Some women develop an early menopause when taking some cytotoxic drugs.

Summary about side effects and checklist
You should discuss with your doctor the particular risks and concerns for the drugs which are used in your own treatment. As a general 'checklist', whilst you are going through a course of chemotherapy, see your doctor as soon as possible if you:

• develop a fever (high temperature), or sweats.
• develop other symptoms which may be due to an infection. For example, a sore throat, pain on passing urine, a cough, breathlessness, or the skin around a catheter site (if you have one inserted) becomes red or sore.
• develop easy bruising, bleed easily, or have any abnormal bleeding.
• have persistent or severe vomiting, particularly if you cannot keep fluids down.
• develop constipation or diarrhoea.
• have other symptoms which you are unhappy with.

Some other points about chemotherapy

Before starting chemotherapy
Depending on the drugs used, you may have a number of 'baseline' blood tests to check that your liver and kidneys are working well. You may also have a heart check (a cardiograph etc) and a check on your lung function. This is because some drugs may affect these organs. These tests may be repeated during treatment to check that these organs continue to work well.

Pregnancy and contraception
Although some cytotoxic drugs can reduce fertility, pregnancy is still possible if you are sexually active. However, cytotoxic drugs can damage sperm, ova and an unborn baby. Therefore, it is not advisable to become pregnant if you are a female who is having chemotherapy, or a female partner of a male who is having chemotherapy. If you are sexually active you should use reliable contraception.

Check with your doctor how long to continue contraception for after treatment is finished. It can be two years or more before it is safe to try for a pregnancy.

Chemotherapy and later cancer
There is a small risk that cytotoxic drugs may cause another form of cancer much later in your life.

Some cytotoxic drugs can

• Interfere or react with other medicines. Check with your doctor about any other medicines that you take.
• Be affected by alcohol. Check with your doctor if you can drink alcohol with your treatment.
• Make you dizzy or too ill to drive. It is usually best not to drive yourself to and from hospital for chemotherapy treatment.

If you have any concerns about your treatment
Do not hesitate to ask your doctor or nurse for help and advice.

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