Some types of chemotherapy make it harder for your bone marrow to produce new white blood cells. White blood cells help your body fight infection. Therefore, it is important to avoid infections, since chemotherapy decreases the number of your white blood cells.

There are many types of white blood cells. One type is called neutrophil. When your neutrophil count is low, it is called neutropenia. Your doctor or nurse may do blood tests to find out whether you have neutropenia.

It is important to watch for signs of infection when you have neutropenia. Check for fever at least once a day, or as often as your doctor or nurse tells you to. You may find it best to use a digital thermometer. Call your doctor or nurse if your temperature is 100.5°F or higher.

• Your doctor or nurse will check your white blood cell count throughout your treatment. If chemotherapy is likely to make your white blood cell count very low, you may get medicine to raise your white blood cell count and lower your risk of infection.
• Wash your hands often with soap and water. Be sure to wash your hands before cooking and eating, and after you use the bathroom, blow your nose, cough, sneeze, or touch animals. Carry hand sanitizer for times when you are not near soap and water.
• Use sanitizing wipes to clean surfaces and items that you touch. This includes public telephones, ATM machines, doorknobs, and other common items.
• Be gentle and thorough when you wipe yourself after a bowel movement. Instead of toilet paper, use a baby wipe or squirt of water from a spray bottle to clean yourself. Let your doctor or nurse know if your rectal area is sore or bleeds or if you have hemorrhoids.
• Stay away from people who are sick. This includes people with colds, flu, measles, or chicken pox. You also need to stay away from children who just had a “live virus” vaccine for chicken pox or polio. Call your doctor, nurse, or local health department if you have any questions.
• Stay away from crowds. Try not to be around a lot of people. For instance, plan to go shopping or to the movies when the stores and theaters are less crowded.

• Be careful not to cut or nick yourself. Do not cut or tear your nail cuticles. Use an electric shaver instead of a razor. And be extra careful when using scissors, needles, or knives.
• Watch for signs of infection around your catheter. Signs include drainage, redness, swelling, or soreness. Let your doctor or nurse know about any changes you notice near your catheter.
• Maintain good mouth care. Brush your teeth after meals and before you go to bed. Use a very soft toothbrush. You can make the bristles even softer by running hot water over them just before you brush. Use a mouth rinse that does not contain alcohol. Check with your doctor or nurse before going to the dentist.
• Take good care of your skin. Do not squeeze or scratch pimples. Use lotion to soften and heal dry, cracked skin. Dry yourself after a bath or shower by gently patting (not rubbing) your skin.
• Clean cuts right away. Use warm water, soap, and an antiseptic to clean your cuts. Do this every day until your cut has a scab over it.
• Be careful around animals. Do not clean your cat’s litter box, pick up dog waste, or clean bird cages or fish tanks. Be sure to wash your hands after touching pets and other animals.
• Do not get a flu shot or other type of vaccine without first asking your doctor or nurse. Some vaccines contain a live virus, which you should not be exposed to.
• Keep hot foods hot and cold foods cold. Do not leave leftovers sitting out. Put them in the refrigerator as soon as you are done eating.

• Wash raw vegetables and fruits well before eating them.
• Do not eat raw or undercooked fish, seafood, meat, chicken, or eggs. These may have bacteria that can cause infection.

• Do not have food or drinks that are moldy, spoiled, or past the freshness date.
• Call your doctor right away (even on the weekend or in the middle of the night) if you think you have an infection. Be sure you know how to reach your doctor after office hours and on weekends. Call if you have a fever of 100.5°F or higher, or when you have chills or sweats. Do not take aspirin, acetaminophen (such as Tylenol®), ibuprofen products, or any other drugs that reduce fever without first talking with your doctor or nurse. Other signs of infection include:
  • Redness
  • Swelling
  • Rash
  • Chills
  • Cough
  • Earache
  • Headache
  • Stiff neck
  • Bloody or cloudy urine
  • Painful or frequent need to urinate
  • Sinus pain or pressure

Hair loss (also called alopecia) is when some or all of your hair falls out. This can happen anywhere on your body: your head, face, arms, legs, underarms, or the pubic area between your legs. Many people are upset by the loss of their hair and find it the most difficult part of chemotherapy.

Some types of chemotherapy damage the cells that cause hair growth. Hair loss often starts 2 to 3 weeks after chemotherapy begins. Your scalp may hurt at first. Then you may lose your hair, either a little at a time or in clumps. It takes about 1 week for all your hair to fall out. Almost always, your hair will grow back 2 to 3 months after chemotherapy is over. You may notice that your hair starts growing back even while you are getting chemotherapy.

Your hair will be very fine when it starts growing back. Also, your new hair may not look or feel the same as it did before. For instance, your hair may be thin instead of thick, curly instead of straight, and darker or lighter in color.

Hair often grows back 2 to 3 months after chemotherapy is over.

Before hair loss:

• Talk with your doctor or nurse. He or she will know if you are likely to have hair loss.
• Cut your hair short or shave your head. You might feel more in control of hair loss if you first cut your hair or shave your head. This often makes hair loss easier to manage. If you shave your head, use an electric shaver instead of a razor.

• If you plan to buy a wig, do so while you still have hair. The best time to choose your wig is before chemotherapy starts. This way, you can match the wig to the color and style of your hair. You might also take it to your hair dresser who can style the wig to look like your own hair. Make sure to choose a wig that feels comfortable and does not hurt your scalp.
• Ask if your insurance company will pay for a wig. If it will not, you can deduct the cost of your wig as a medical expense on your income tax. Some groups also have free “wig banks.” Your doctor, nurse, or social worker will know if there is a wig bank near you.
• Be gentle when you wash your hair. Use a mild shampoo, such as a baby shampoo. Dry your hair by patting (not rubbing) it with a soft towel.
• Do not use items that can hurt your scalp. These include:
  • Straightening or curling irons
  • Brush rollers or curlers
  • Electric hair dryers
  • Hair bands and clips
  • Hairsprays
  • Hair dyes
  • Products to perm or relax your hair
• Protect your scalp. Your scalp may hurt during and after hair loss. Protect it by wearing a hat, turban, or scarf when you are outside. Try to avoid places that are very hot or very cold. This includes tanning beds and outside in the sun or cold air. And always apply sunscreen or sunblock to protect your scalp.
• Stay warm. You may feel colder once you lose your hair. Wear a hat, turban, scarf, or wig to help you stay warm.

• Sleep on a satin pillow case. Satin creates less friction than cotton when you sleep on it. Therefore, you may find satin pillow cases more comfortable.

Talk about your feelings. Many people feel angry, depressed, or embarrassed about hair loss. If you are very worried or upset, you might want to talk about these feelings with a doctor, nurse, family member, close friend, or someone who has had hair loss caused by cancer treatment.

Fatigue from chemotherapy can range from a mild to extreme feeling of being tired. Many people describe fatigue as feeling weak, weary, worn out, heavy, or slow. Resting does not always help.

Many people say they feel fatigue during chemotherapy and even for weeks or months after treatment is over. Fatigue can be caused by the type of chemotherapy, the effort of making frequent visits to the doctor, or feelings such as stress, anxiety, and depression. If you receive radiation therapy along with chemotherapy, your fatigue may be more severe.

Fatigue can also be caused by

• Anemia
• Pain
• Medications
• Appetite changes
• Trouble sleeping
• Lack of activity
• Trouble breathing
• Infection
• Doing too much at one time
• Other medical problems

Fatigue can happen all at once or little by little. People feel fatigue in different ways. You may feel more or less fatigue than someone else who gets the same type of chemotherapy.

Ways to manage

• Relax. You might want to try meditation, prayer, yoga, guided imagery, visualization, or other ways to relax and decrease stress.
• Eat and drink well. Often, this means 5 to 6 small meals and snacks rather than 3 large meals. Keep foods around that are easy to fix, such as canned soups, frozen meals, yogurt, and cottage cheese. Drink plenty of fluids each day–about 8 cups of water or juice.

Plan time to rest. You may feel better when you rest or take a short nap during the day. Many people say that it helps to rest for just 10 to 15 minutes rather than nap for a long time. If you nap, try to sleep for less than 1 hour. Keeping naps short will help you sleep better at night.

• Be active. Research shows that exercise can ease fatigue and help you sleep better at night. Try going for a 15-minute walk, doing yoga, or riding an exercise bike. Plan to be active when you have the most energy. Talk with your doctor or nurse about ways you can be active while getting chemotherapy.
• Try not to do too much. With fatigue, you may not have enough energy to do all the things you want to do. Choose the activities you want to do and let someone else help with the others. Try quiet activities, such as reading, knitting, or learning a new language on tape.

Sleep at least 8 hours each night. This may be more sleep than you needed before chemotherapy. You are likely to sleep better at night when you are active during the day. You may also find it helpful to relax before going to bed. For instance, you might read a book, work on a jigsaw puzzle, listen to music, or do other quiet hobbies.

• Plan a work schedule that works for you. Fatigue may affect the amount of energy you have for your job. You may feel well enough to work your full schedule. Or you may need to work less–maybe just a few hours a day or a few days each week. If your job allows, you may want to talk with your boss about ways to work from home. Or you may want to go on medical leave (stop working for a while) while getting chemotherapy.
• Let others help. Ask family members and friends to help when you feel fatigue. Perhaps they can help with household chores or drive you to and from doctor’s visits. They might also help by shopping for food and cooking meals for you to eat now or freeze for later.
• Learn from others who have cancer. People who have cancer can help by sharing ways that they manage fatigue. One way to meet others is by joining a support group–either in person or online. Talk with your doctor or nurse to learn more.

• Try not to do too much. With fatigue, you may not have enough energy to do all the things you want to do. Choose the activities you want to do and let someone else help with the others. Try quiet activities, such as reading, knitting, or learning a new language on tape.

• Keep a diary of how you feel each day. This will help you plan how to best use your time. Share your diary with your nurse. Let your doctor or nurse know if you notice changes in your energy level, whether you have lots of energy or are very tired.
• Talk with your doctor or nurse. Your doctor may prescribe medication that can help decrease fatigue, give you a sense of well-being, and increase your appetite. He or she may also suggest treatment if your fatigue is from anemia.

Diarrhea is frequent bowel movements that may be soft, loose, or watery. Chemotherapy can cause diarrhea because it harms healthy cells that line your large and small bowel. It may also speed up your bowels. Diarrhea can also be caused by infections or drugs used to treat constipation.

Ways to manage:

• Eat 5 or 6 small meals and snacks each day instead of 3 large meals.
• Ask your doctor or nurse about foods that are high in salts such as sodium and potassium. Your body can lose these salts when you have diarrhea, and it is important to replace them. Foods that are high in sodium or potassium include bananas, oranges, peach and apricot nectar, and boiled or mashed potatoes.
• Drink 8 to 12 cups of clear liquids each day. These include water, clear broth, ginger ale, or sports drinks such as Gatorade® or Propel®. Drink slowly, and choose drinks that are at room temperature. Let carbonated drinks lose their fizz before you drink them. Add extra water if drinks make you thirsty or nauseous (feeling like you are going to throw up).
• Eat low-fiber foods. Foods that are high in fiber can make diarrhea worse. Low-fiber foods include bananas, white rice, white toast, and plain or vanilla yogurt.
• Let your doctor or nurse know if your diarrhea lasts for more than 24 hours or if you have pain and cramping along with diarrhea. Your doctor may prescribe a medicine to control the diarrhea. You may also need IV fluids to replace the water and nutrients you lost. Do not take any medicine for diarrhea without first asking your doctor or nurse.

Ask your doctor or nurse before taking medicine for diarrhea.

• Be gentle when you wipe yourself after a bowel movement. Instead of toilet paper, use a baby wipe or squirt of water from a spray bottle to clean yourself after bowel movements. Let your doctor or nurse know if your rectal area is sore or bleeds or if you have hemorrhoids.

Ask your doctor if you should try a clear liquid diet. This can give your bowels time to rest. Most people stay on this type of diet for 5 days or less.

Stay away from:

• Drinks that are very hot or very cold
• Beer, wine, and other types of alcohol
• Milk or milk products, such as ice cream, milkshakes, sour cream, and cheese
• Spicy foods, such as hot sauce, salsa, chili, and curry dishes
• Greasy and fried foods, such as french fries and hamburgers
• Foods or drinks with caffeine, such as regular coffee, black tea, cola, and chocolate
• Foods or drinks that cause gas, such as cooked dried beans, cabbage, broccoli, and soy milk and other soy products

Foods that are high in fiber, such as cooked dried beans, raw fruits and vegetables, nuts, and whole-wheat breads and cereals

Constipation is when bowel movements become less frequent and stools are hard, dry, and difficult to pass. You may have painful bowel movements and feel bloated or nauseous. You may belch, pass a lot of gas, and have stomach cramps or pressure in the rectum.

Drugs such as chemotherapy and pain medicine can cause constipation. It can also happen when people are not active and spend a lot of time sitting or lying down. Constipation can also be due to eating foods that are low in fiber or not drinking enough fluids.

Ways to manage

• Keep a record of your bowel movements. Show this record to your doctor or nurse and talk about what is normal for you. This makes it easier to figure out whether you have constipation.
• Drink at least 8 cups of water or other fluids each day. Many people find that drinking warm or hot fluids, such as coffee and tea, helps with constipation. Fruit juices, such as prune juice, may also be helpful.
• Be active every day. You can be active by walking, riding a bike, or doing yoga. If you cannot walk, ask about exercises that you can do in a chair or bed. Talk with your doctor or nurse about ways you can be more active.
• Ask your doctor, nurse, or dietitian about foods that are high in fiber. Eating high fiber foods and drinking lots of fluids can help soften your stools. Good sources of fiber include whole-grain breads and cereals, dried beans and peas, raw vegetables, fresh and dried fruit, nuts, seeds, and popcorn.

When you eat more fiber, be sure to drink more fluids.

• Let your doctor or nurse know if you have not had a bowel movement in 2 days. Your doctor may suggest a fiber supplement, laxative, stool softener, or enema. Do not use these treatments without first checking with your doctor or nurse. Check with your doctor or nurse before using fiber supplements, laxatives, stool softeners, or enemas.

Radiation therapy can cause tissue and bone in the treated area to waste away. When tissue death occurs, ulcers may form in the soft tissues of the mouth, grow in size, and cause pain or loss of feeling. Infection becomes a risk. As bone tissue is lost, fractures can occur. Preventive care can lessen the severity of tissue and bone loss.

Treatment of tissue and bone loss may include the following:

• Eating a well-balanced diet.
• Wearing removable dentures or appliances as little as possible.
• Not smoking.
• Not drinking alcohol.
• Using topical antibiotics.
• Using painkillers.
• Undergoing surgery to remove dead bone or to reconstruct bones of the mouth and jaw.
• Receiving hyperbaric oxygen therapy, a method of delivering oxygen under pressure to the surface of a wound to help it heal.

Pain in the teeth or jaw muscles may occur in patients who grind their teeth or clench their jaws, often because of stress or the inability to sleep. Treatment may include the following:

• Muscle relaxers.
• Drugs to treat anxiety.
• Physical therapy (moist heat, massage, and stretching).
• Mouthguards to wear while sleeping.

Jaw Stiffness

A long-term complication of radiation therapy is the growth of benign tumors in the skin and muscles. These tumors may make it difficult for the patient to move the mouth and jaw normally. Oral surgery may also affect jaw mobility. Management of jaw stiffness may include the following:

• Physical therapy.
• Oral appliances.
• Pain treatments.
• Medication.

Loss of appetite can lead to malnutrition.

Patients undergoing treatment for head and neck cancers are at high risk for malnutrition. The cancer itself, poor diet before diagnosis, and complications from surgery, radiation therapy, and chemotherapy can lead to nutritional shortfalls. Patients can lose the desire to eat due to nausea, vomiting, trouble swallowing, sores in the mouth, or dry mouth. When eating causes discomfort or pain, the patient’s quality of life and nutritional well-being suffer. The following suggestions may help patients with cancer meet their nutritional needs:

• Change the texture of food. Serving food chopped, ground, or blended can reduce the amount of time it needs to stay in the mouth before being swallowed.
• Eat between-meal snacks to add calories and nutrients.
• Choose foods high in calories and protein.
• Take supplements that provide vitamins, minerals, and calories.

Nutritional counseling may be helpful during and after treatment.

Nutritional support may include liquid diets and enteral feedings.

Many patients treated for head and neck cancers who receive radiation therapy alone are able to eat soft foods. As treatment progresses, most patients will include or switch to liquid diets using high-calorie, high-protein nutritional drinks. Some patients may need enteral tube feeding to meet their nutritional needs. Almost all patients who receive chemotherapy and head and/or neck radiation therapy at the same time will require enteral nutritional support within 3 to 4 weeks. Studies show that patients benefit when they begin enteral feedings at the start of treatment, before weight loss occurs.

Normal eating by mouth begins again when treatment is finished and the site that received radiation is healed. The return to normal eating often needs a team approach, including a speech and swallowing therapist to ease the adjustment back to solid foods. Tubefeedings are decreased as a patient’s intake by mouth increases, and are stopped when the patient is able to get enough nutrients by mouth. Although most patients will regain their ability to eat solid foods, many will have lasting complications such as taste

Changes in taste are common during chemotherapy and radiation therapy.

Change in the sense of taste is a common side effect of both chemotherapy and head and/or neck radiation therapy. Foods may have no taste or may not taste as they did before therapy. These taste changes are caused by damage to the taste buds, dry mouth, infection, and/or dental problems. Chemotherapy patients may experience unpleasant taste related to the spread of the drug within the mouth. Radiation may cause a change in sweet, sour, bitter, and salty tastes.

In most patients receiving chemotherapy and in some patients undergoing radiation therapy, taste returns to normal a few months after therapy ends. For many radiation therapy patients, however, the change is permanent. In others, the taste buds may recover 6 to 8 weeks, or later, after radiation therapy ends. Zinc sulfate supplements may help with the recovery for some patients.

Saliva is needed for taste, swallowing, and speech. It helps prevent infection and tooth decay by neutralizing acid and cleaning the teeth and gums. Radiation therapy can damage salivary glands, causing them to make too little saliva. The mouth is less able to clean itself. Acid in the mouth is not neutralized, and minerals are lost from the teeth. Tooth decay and gum disease are more likely to develop. In addition, there is some evidence that salivary glands may be damaged by certain types of chemotherapy drugs given alone or in combination. Symptoms of dry mouth include the following:

• Thick, stringy saliva.
• Increased thirst.
• Changes in taste, swallowing, and speech.
• A sore or burning feeling (especially on the tongue).
• Cuts or cracks in the lips or at the corners of the mouth.
• Changes in the surface of the tongue.
• Difficulty wearing dentures.

Salivary glands may not recover completely after radiation therapy ends.

Saliva production drops within 1 week after starting radiation therapy to the head and/or neck and continues to decrease as treatment continues. The severity of dry mouth depends on the dose of radiation and the number of glands irradiated. The salivary glands in the upper cheeks near the ears are more affected than other salivary glands.

Partial recovery of salivary glands may occur in the first year after radiation therapy, but recovery is usually not complete, especially if the salivary glands were directly irradiated. Salivary glands that were not irradiated may become more active to offset the loss of saliva from the destroyed glands.

Careful oral hygiene can help prevent mouth sores, gum disease, and tooth decay caused by dry mouth.

The following are guidelines for managing dry mouth:

• Clean the mouth and teeth at least 4 times a day.
• Floss once a day.
• Use a fluoride toothpaste when brushing.
• Apply fluoride gel once a day at bedtime, after cleaning the teeth.
• Rinse 4 to 6 times a day with a solution of salt and baking soda (mix ½ teaspoon salt and ½ teaspoon baking soda in 1 cup of warm water). Avoid foods and liquids that contain a lot of sugar. Sip water to relieve mouth dryness.

A dentist can provide the following treatments:

• Solutions to replace minerals in the teeth.
• Rinses to fight infection in the mouth.
• Saliva substitutes or medications to stimulate the salivary glands.
• Fluoride treatments to prevent tooth decay.

Tooth Decay

Dry mouth and changes in the balance of oral bacteria increase the risk of tooth decay. Meticulous oral hygiene (as described in Routine Oral Care) and regular care by a dentist can help prevent cavities.