Managing Side Effects

Are side effects the same for everyone?

The side effects of radiation treatment vary from patient to patient. You may have no side effects or only a few mild ones through your course of treatment. Or you may have more serious side effects. The side effects that you have depend mostly on the treatment dose and the part of your body that is treated. Your general health also can affect how your body reacts to radiation therapy and whether you have side effects. Before beginning your treatment, ask your doctor and nurse about the side effects you might experience, how long they might last, and how serious they might be.

There are two main types of side effects: acute and chronic. Acute, or short-term, side effects occur close to the time of the treatment and usually are gone completely within a few weeks of finishing therapy. Chronic, or long-term, side effects may take months or years to develop and usually are permanent.

The most common side effects are fatigue, skin changes, and loss of appetite. They can result from radiation to any treatment site. Other side effects are related to treatment of specific areas. For example, temporary or permanent hair loss may be a side effect of radiation treatment to the head. Fortunately, most side effects will go away in time. In the meantime, there are ways to reduce the discomfort they cause. If you have a side effect that is particularly severe, the doctor may prescribe a break in your treatments or change the kind of treatment you're receiving.

Be sure to tell your doctor, nurse, or radiation therapist about any side effects that you notice. They can help you treat the problems and tell you how to lessen the chances that the side effects will come back.

Will side effects limit my activities?

Not necessarily. It will depend on what side effects you have and how severe they are. Many patients are able to go to work, keep house, and enjoy leisure activities while they are receiving radiation therapy. Others find that they need more rest than usual and therefore cannot do as much. You should try to do the things you enjoy as long as you don't become too tired.

Your doctor may suggest that you limit activities that might irritate the area being treated. In most cases, you can have sexual relations if you wish. Your desire for physical intimacy may be lower because radiation therapy may cause you to feel more tired than usual.

What causes fatigue?

During radiation therapy, the body uses a lot of energy healing itself. Stress related to your illness, daily trips for treatment, and the effects of radiation on normal cells all may contribute to fatigue. Most people begin to feel tired after a few weeks of radiation therapy. Feelings of weakness or weariness will go away gradually after your treatment is finished.

You can help yourself during radiation therapy by not trying to do too much. If you feel tired, limit your activities and use your leisure time in a restful way. Do not feel that you have to do all the things you normally do. Try to get more sleep at night, and rest during the day if you can.

If you have been working a full-time job, you may want to continue. Although treatment visits are time-consuming, you can ask your doctor's office or the radiation therapy department to help by trying to schedule treatments with your workday in mind.

Some patients prefer to take a few weeks off from work while they're receiving radiation therapy; others work a reduced number of hours. You may want to speak frankly with your employer about your needs and wishes during this time. You may be able to agree on a part-time schedule, or perhaps you can do some work at home.

Whether you're going to work or not, it's a good idea to ask family members or friends to help with daily chores, shopping, child care, housework, or driving. Neighbors may be able to help by picking up groceries for you when they do their own shopping. You also could ask someone to drive you to and from your treatment visits to help conserve your energy.

How are skin problems treated?

You may notice that your skin in the treatment area may begin to look reddened, irritated, sunburned, or tanned. After a few weeks you may have very dry skin from the therapy. Ask your doctor or nurse for advice on relieving itching or discomfort. With some kinds of radiation therapy, treated skin may develop a "moist reaction," especially in areas where there are skin folds. When this happens, the skin is wet and it may become very sore. It's important to notify your doctor or nurse if your skin develops a moist reaction. They can give you some suggestions on how you can keep these areas dry.

During radiation therapy you will need to be very gentle with the skin in the treatment area. Avoid irritating treated skin. When you wash, use only lukewarm water and mild soap. Don't wear tight clothing over the area. It's important not to rub, scrub, or scratch any sensitive spots. Also avoid putting anything that is very hot or very cold, such as heating pads or ice packs, on your treated skin. Don't use any powders, creams, perfumes, deodorants, body oils, ointments, lotions, or home remedies in the treatment area while you're being treated or for several weeks afterward (unless approved by your doctor or nurse). Many skin products can leave a coating on the skin that can interfere with radiation therapy or healing.

Avoid exposing the area to the sun during treatment and for at least I year after your treatment is completed. If you expect to be in the sun for more than a few minutes you will need to be very careful. Wear protective clothing (such as a hat with a broad brim and a shirt with long sleeves) and use a sunscreen. Ask your doctor or nurse about using sunblocking lotions.

The majority of skin reactions to radiation therapy should go away a few weeks after treatment is finished. In some cases, though, the treated skin will remain darker than it was before.

What can be done about hair loss?

Radiation therapy can cause hair loss, also known as alopecia, but only in the area being treated. For example, if you are receiving treatment to your hip, you will not lose the hair from your head. However, radiation to your head may cause you to lose some or all of the hair on your scalp. Many patients find that their hair grows back again after the treatments are finished, but accepting the loss of hair -whether from scalp, face, or body - can be a hard adjustment. The amount of hair that grows back will depend on how much radiation you receive and the type of radiation treatment your doctor recommends. Other types of treatment, such as chemotherapy, also can affect how your hair grows back. For example, if your radiation therapy is for palliative care, your hair probably will grow back slowly. However, if the goal of your radiation therapy is to cure rather than to relieve the symptoms of your cancer, then your hair may not grow back, and if it does, it probably will be very fine.

Although your scalp may be tender after the hair is lost, you may want to cover your head with a hat, turban, or scarf while you're in treatment. Also, you should wear a protective cap or scarf when you're in the sun. If you prefer a wig or toupee, be sure the lining does not irritate your scalp. A hairpiece that you need because of cancer treatment is a tax-deductible expense and may be covered in part by your health insurance. If you plan to buy a wig, it's a good idea to select it early in your treatment so that you can match the color and style to your own hair.

What about side effects on the blood?

Sometimes radiation therapy can cause low white blood cell counts or low levels of platelets. These blood cells help your body fight infection and prevent bleeding. If your blood tests show this side effect, your treatment might be delayed for about a week to allow your blood counts to increase.

What if there are eating problems?

Many side effects can cause problems with eating and digesting food, but you always should try to eat enough to help damaged tissues rebuild themselves. It's very important not to lose weight during radiation therapy. Try to eat small meals often and eat a variety of different foods. Your doctor or nurse can tell you whether your treatment calls for a special diet and a dietitian will have a lot of ideas to help you maintain your weight.

If you have pain when you chew and swallow, your doctor may advise you to use a powdered or liquid diet supplement. Many of these products, available at the drugstore without prescription, are made in a variety of flavors. They are tasty when used alone, or they can be combined with other foods, such as pureed fruit, or added to milkshakes. Some of the companies that make diet supplements have produced recipe booklets to help you increase your nutrient intake. Ask your dietitian or pharmacist for further information.

You may lose interest in food during your treatment. Loss of appetite can happen when changes occur in normal cells. Some people just don't feel like eating because of stress from their illness and treatment or because the treatment changes the way foods taste. Even if you're not very hungry, it's important that you make every effort to keep your protein and calorie intake high. Doctors have found that patients who eat well can better handle both their cancer and the side effects of treatment.

The list below suggests ways to perk up your appetite when it's poor and to make the most of it when you do feel like eating.

• Eat when you are hungry, even if it is not mealtime.
• Eat several small meals during the day rather than three large ones.
• Use soft lighting, quiet music, brightly colored table settings, or whatever helps you feel good while eating.
• Vary your diet and try new recipes.
• If you enjoy company while eating, try to have meals with family or friends, or turn on the radio or television.
• Ask your doctor or nurse whether you can have a glass of wine or beer with your meal to increase your appetite. Keep in mind that in some cases, alcohol may not be allowed because of the chance that it will worsen the side effects of treatment. This may be especially true if you are receiving radiation therapy for cancer of the head or neck.
• When you feel up to it, make some simple meals in batches and freeze them to use later.
• Keep healthy snacks close by for nibbling when you get the urge.
• If other people offer to cook for you, let them. Don't be shy about telling them what you'd like to eat.
• If you live alone, you might want to arrange for "Meals on Wheels" to bring food to you. Ask your doctor, nurse, local American Cancer Society office, or Cancer Information Service about "Meals on Wheels." This service is active in most large communities.
• If you are able to eat only small amounts of food, you can increase the calories per serving by trying the following ideas:
  • Add butter or margarine if you like the flavor.
  • Mix canned cream soups with milk or half-and-half rather than water.
  • Drink eggnogs, milkshakes, or prepared liquid supplements between meals.
  • Add cream sauce or melted cheese to your favorite vegetables.
• Some people find they can handle large amounts of liquids even when they don't feel like eating solid foods. If this is the case for you, try to get the most from each glassful by having drinks enriched with powdered milk, yogurt, honey, or prepared liquid supplements.

Does radiation affect the emotions?

Nearly all patients who receive treatment for cancer feel some degree of emotional upset. It's not unusual to feel depressed, afraid, angry, frustrated, alone, or helpless. Radiation therapy may affect the emotions indirectly through fatigue or changes in hormone balance, but the treatment itself is not a direct cause of mental distress.

Many patients help themselves by talking about their feelings with a close friend, family member, chaplain, nurse, social worker, or psychologist with whom they feel at ease. You may want to ask your doctor or nurse about meditation or relaxation exercises that could help you unwind and feel better. American Cancer Society nationwide programs can provide support. Groups such as the United Ostomy Association and the Lost Chord Club offer opportunities to meet with others who share the same problems and concerns. Some medical centers have formed peer support groups so that patients can meet to discuss their feelings and inspire each other.

What side effects occur with radiation therapy to the head and neck area?

Some people who are having radiation to the head and neck have redness and irritation in the mouth, a dry mouth, difficulty in swallowing, changes in taste, or nausea. Try not to let these symptoms keep you from eating.

Other problems that may occur during treatment to the head and neck are a loss of your sense of taste, earaches (caused by hardening of ear wax), and swelling or drooping of skin under the chin. There may be changes in your skin texture. You also may notice that your jaw feels stiff and that you cannot open your mouth as wide as before your treatment. Jaw exercises may help this problem. Report any side effects to your doctor or nurse and ask what you should do about them.

If you are receiving radiation therapy to the head or neck, you need to take especially good care of your teeth, gums, mouth, and throat. Side effects from treatment to these areas most often involve the mouth, which may be sore and dry. Here are a few tips that may help you manage mouth problems:

• Avoid spices and coarse foods such as raw vegetables, dry crackers, and nuts.
• Don't smoke, chew tobacco, or drink alcohol.
• Stay away from sugary snacks that promote tooth decay.
• Clean your mouth and teeth often, using the method your dentist or doctor recommends.
• Do not use a commercial mouthwash; the alcohol content has a drying effect on mouth tissues.

Dental Care

Radiation treatment for head and neck cancer can increase your chances of getting cavities. Mouth care designed to prevent problems will be a very important part of your treatment. Before starting radiation therapy, notify your dentist and arrange for a complete dental/oral checkup. Ask your dentist to consult with your radiation oncologist about any dental work you need before your radiation treatments begin.

Handling Mouth or Throat Problems

Soreness in your mouth or throat may appear in the second or third week of external radiation therapy. It is likely to decrease from the fifth week on and end a month or so after your treatment ends. You may have trouble swallowing during this time because your mouth feels dry. Your doctor or dentist can prescribe medicine for mouth discomfort and advise you about methods to relieve other mouth problems.

If you wear dentures you may notice that they no longer fit well. This may happen if the radiation causes swelling in your gums. It's important not to let your dentures cause gum sores that may become infected. You may need to stop wearing your dentures until your radiation therapy is over.

Your glands may produce less saliva than usual, making your mouth feel dry. It's helpful to sip cool drinks often throughout the day. Water probably is your best choice. In the morning, fill up a large cup or glass with ice, add water, and carry it with you so you have something to drink during the day. Keep a glass of cool water at your bedside at night, too. Many radiation therapy patients say that drinking carbonated beverages helps relieve dry mouth. Sugar-free candy or gum also may help. Avoid tobacco and alcoholic drinks because they will dry and irritate your mouth tissues even more. Moisten food with gravies and sauces to make eating easier. If these measures are not enough, ask your dentist about artificial saliva. Dry mouth may continue to be a problem even after treatment is over.

Tips on Eating

If you are having radiation therapy to the chest, you may find swallowing difficult or painful. Some patients say that it feels like something is stuck in their throat.

Soreness or dryness in your mouth or throat can make it hard to eat. However, there are several ways to ease your discomfort:

• Choose foods that taste good to you and are easy to eat.
• Try changing the consistency of foods by adding fluids and using sauces and gravies to make them softer.
• Avoid highly spiced foods and textures that are dry and rough, such as crackers.
• Eat small meals, and eat more frequently than usual.
• Cut your food into small, bite-sized pieces.
• Ask your doctor for special liquid medicines that can help you eat and swallow more easily by reducing the pain in your throat.
• Ask your doctor about liquid food supplements. These can help you meet your energy needs.
• If you are being treated for lung cancer, and you get your doctor's okay, try to drink extra fluids. This will help keep mucus and other secretions thin and manageable.
• If your sense of taste changes during radiation therapy, try different methods of food preparation.

What side effects occur with radiation therapy to the breast and chest?

Radiation treatment to the chest may cause several changes. You will notice some of these changes yourself, and your treatment team will keep an eye on these and others. For example, you may find that it is hard to swallow or that swallowing hurts. You may develop a cough. Or you may develop a fever, notice a change in the color or amount of mucus when you cough, or feel short of breath. It is important to let your treatment team know right away if you have any of these symptoms. Your doctor also may check your blood counts regularly, especially if the radiation treatment area on your body is large. Just keep in mind that your doctor and nurse will be alert for these changes and will help you deal with them.

If you are receiving radiation therapy after a lumpectomy or mastectomy, it's a good idea to go without wearing a bra whenever possible. If this is not possible, wear a soft cotton bra without underwires. This will help reduce the irritation to your skin in the treatment area. You may have several other side effects if you are receiving radiation therapy for breast cancer. For example, you may notice a lump in your throat or develop a dry cough. Or, your shoulder may feel stiff; if so, ask your doctor or nurse about exercises to keep your arm moving freely. Other side effects that may appear are breast soreness and swelling from fluid buildup in the treated area. These side effects, as well as skin reddening or tanning, most likely will disappear in 4 to 6 weeks. If fluid buildup continues to be a problem, your doctor will tell you what steps to take.

Women who have radiation therapy after a lumpectomy may notice other changes in the breast after the therapy. These long-term side effects may continue for a year or longer after treatment. The redness of the skin will fade, and you may notice that your skin is slightly darker, just as when a sunburn fades to a suntan. The pores may be enlarged and more noticeable. Some women report increased sensitivity of the skin on the breast; others have decreased feeling. The skin and the fatty tissue of the breast may feel thicker, and you may notice that your breast is firmer than it was before your radiation treatment. Sometimes the size of your breast changes -it may become larger because of fluid buildup or smaller because of the development of fibrous tissue. Many women have little or no change in size.

Your radiation therapy plan may include implants of radioactive material a week or two after external treatment is completed. You may have some breast tenderness or a feeling of tightness while the implants are in your breast. After they are removed, you are likely to notice some of the same effects that occur with external treatment. If so, follow the advice given above and let your doctor know about any problems that persist.

After 10 to 12 months, no further changes are likely to be caused by the radiation therapy. If you see new changes in breast size, shape, appearance, or texture after this time, report them to your doctor at once.

What side effects occur with radiation therapy to the stomach and abdomen?

If you are having radiation treatment to the stomach or some portion of the abdomen, you may have to deal with an upset stomach, nausea, or diarrhea. Your doctor can prescribe medicines to relieve these problems. Do not take any home remedies during your treatment unless you first check with your doctor or nurse.

Managing Nausea

Some patients report feeling queasy for a few hours right after radiation therapy to the stomach or abdomen. If you have this problem, do not eat for several hours before your treatment time. You may be able to handle the treatment better on an empty stomach. After your treatment, you may find it helpful to wait 1 to 2 hours before eating again. If the problem persists, ask your doctor to prescribe a medicine (an antiemetic) to prevent nausea. If antiemetics are prescribed, try to take them when your doctor suggests, even if you sometimes feel that they are not needed.

If your stomach feels upset just before your treatment, try a bland snack such as toast or crackers and apple juice before your appointment. This type of side effect may be related to your emotions and concerns about treatment. Try to unwind a bit before you have your treatment. If you have to spend time in a waiting room, reading a book, writing letters, or working a crossword puzzle may help you relax.

Here are some tips to help an unsettled stomach:

• Stick to any special diet that your doctor or dietitian gives you.
• Eat small meals.
• Eat often and try to eat and drink slowly.
• Avoid foods that are fried or are high in fat.
• Drink cool liquids between meals.
• Eat foods that have only a mild aroma and those that can be served cool or at room temperature.
• For a severe upset stomach, try a clear liquid diet (broth and juices) or bland foods that are easy to digest, such as dry toast and gelatin.

How To Handle Diarrhea

Diarrhea most often begins in the third or fourth week of radiation therapy. Your doctor may suggest you change your diet, prescribe medicine for you, or give you special instructions to help with the problem. Tell the doctor or nurse if these changes are not controlling your diarrhea.

The following changes in your diet also may help:

• Try a clear liquid diet (water, weak tea, apple juice, clear broth, plain gelatin) as soon as diarrhea starts or when you feel that it's going to start.
• Ask your doctor or nurse to advise you about liquids that won't make your diarrhea worse. Apple juice, peach nectar, weak tea, and clear broth are frequent suggestions.
• Avoid foods that are high in fiber or can cause cramps or a gassy feeling such as raw fruits and vegetables, coffee, beans, cabbage, whole grain breads and cereals, sweets, and spicy foods.
• Eat frequent small meals.
• Avoid milk and milk products if they irritate your bowels.
• When the diarrhea starts to improve, try eating small amounts of low-fiber foods such as rice, bananas, applesauce, mashed potatoes, low-fat cottage cheese, and dry toast.
• Be sure your diet includes foods that are high in potassium (bananas, potatoes, apricots), an important mineral that you may lose through diarrhea.

Diet planning is a very important part of radiation treatment of the stomach and abdomen. Keep in mind that these problems will be reduced greatly when treatment is over. In the meantime, try to pack the highest possible food value into even small meals so that you will have enough calories and vital nutrients.

What side effects occur with radiation therapy to the pelvis?

If you are having radiation therapy to any part of the pelvis (the area between your hips), you might have one or more of the digestive problems already described. You also may have some irritation to your bladder. This can cause discomfort or frequent urination. Drinking fluids can help relieve some of your discomfort. Your doctor can prescribe some medicine to deal with these problems.

There are also certain side effects that occur only in the reproductive organs. The effects of radiation therapy on sexual and reproductive functions depend on which organs are treated. Some of the more common side effects for both men and women do not last long after treatment. Others may be long-term or permanent. Before your treatment begins, ask your doctor about possible side effects and how long they might last.

Effects on Fertility

Scientists are still studying how radiation treatment affects fertility. If you are a women in your childbearing years, you should discuss birth control measures with your doctor. It is not a good idea to become pregnant during radiation therapy. Radiation may injure the fetus. In addition, pregnancy, childbirth, and caring for a very young child can add to the physical and emotional stress of having cancer. If you are pregnant before beginning radiation therapy, special steps should be taken to protect the fetus from radiation.

Depending on the radiation dose, women having radiation therapy in the pelvic area may stop menstruating and may have other symptoms of menopause. Treatment also can result in vaginal itching, burning, and dryness. You should report these symptoms to your doctor or nurse, who can suggest treatment.

For men, radiation therapy to an area that includes the testes can reduce both the number of sperm and their effectiveness. This does not mean that conception cannot occur, however. If you're having this type of treatment, discuss your concerns and your birth control measures with your doctor. If you want to father a child and are concerned about reduced fertility, you can look into the option of banking your sperm before treatment.

Sexual Relations

During treatment to the pelvis, some women are advised not to have intercourse. Others may find that intercourse is painful. You most likely will be able to resume having sex within a few weeks after your treatment ends.

Some shrinking of vaginal tissues occurs during radiation therapy. After your radiation therapy is finished your doctor will advise you about sexual intercourse and how to use a dilator, a device that gently stretches the tissues of the vagina.

With most types of radiation therapy, neither men nor women are likely to suffer any change in their ability to enjoy sex. Both sexes, however, may notice a decrease in their level of desire. This is more likely to be due to the stress of having cancer than to the effects of radiation therapy. This effect most likely will go away when the treatment ends, so it should not become a major concern.

This material was taken from the booklet "Radiation Therapy and You" published by the National Institutes of Health.

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