How to Manage Side Effects During Cancer Treatment: Fatigue, Hair Loss, Skin Care and More

Dr. Diane Reidy-Lagunes:

Advances in cancer treatment have led to increased cure rates for millions of people, yet the side effects of some of that treatment can range from life-threatening to just annoying. They can also be visible: hair loss, skin changes that can be disfiguring, brittle nails and more. These side effects matter. Today we have one of the world's experts to provide his wisdom, as well as a nurse of 26 years who has managed these side effects. They both share their practical advice and more, and we're going to talk about it. 

Hello. I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to empower you and your loved ones to make the right choices and live happier, healthier lives. For more information on the topics discussed here or to send us your questions, please visit us at mskcc.org/podcast.

Today we are so pleased to be joined by Dr. Mario Lacouture and nurse Sheryl Scott. Mario is a dermatologist here at MSK who literally and figuratively wrote the book on how to manage unwanted side effects of hair, skin, and nails while on treatment. His book is entitled Dr. Lacouture's Skincare Guide for People Living with Cancer. He also develops clinical trials to test creams and other therapies that mitigate those side effects.

Sheryl is a senior outpatient nurse in our regional care network in MSK Westchester. She has seen it all and managed these side effects for hundreds if not thousands of patients, and she too will share her wisdom here today. Mario and Sheryl, thank you both so much for coming on the pod today and welcome to the show.

Nurse Sheryl Scott:

Thank you for having us.

Dr. Mario Lacouture:

Thanks Diane. It's great to be here with your audience.

Dr. Diane Reidy-Lagunes:

Mario, I'd like to start just with the basics of an overview. Why does chemotherapy or radiation cause side effects?

Dr. Mario Lacouture:

Chemotherapy and radiation affect rapidly growing cells, of which cancer are characteristic ones. But it also affects rapidly growing normal cells such as those in the skin, in the hair, and the nails. And since the skin is the largest organ in our bodies, it is frequently affected by cancer treatments. In fact, one out of two people will have some type of dermatologic condition as a result of their cancer treatment. And in up to one out of five patients, these can limit their ability to receive treatments.

There are many instances where people are developing side effects that over a long period of time can become disruptive to their quality of life because they are very itchy, for example, people cannot sleep, or they can be very painful. Conditions affecting the fingernails and the toenails can affect a person's ability to use their hands or to walk. Therefore, their cancer treatments may be interrupted.

The good news is that in the majority of cases, by treating these conditions early on, we can prevent them or mitigate them to the point where the treatment can continue, and the quality of life is not impaired.

Dr. Diane Reidy-Lagunes:

Sheryl, you take care of patients with breast cancer and other types of diseases for a very long time. What are the most common side effects that you're dealing with in your patients, or trying to manage in terms of chemotherapy and or radiation treatments?

Nurse Sheryl Scott:

I think probably the number one side effect is fatigue. Some patients who are receiving adjuvant treatment, which would be preventative, can have some fatigue for a certain period of time after their treatment, and then as time goes on that gets better. Other patients who are on a daily treatment can have periods where they need to kind of balance their activities a little bit because of the fact that the fatigue can affect their daily living.

Dr. Diane Reidy-Lagunes:

Let's hear from Stacey who shares her experience regarding fatigue.

Stacey:

Hi, my name is Stacy and I've had cancer for 11 years. I had my first surgery in May of 2012. After that I did IP chemo, which is delivered directly to your peritoneal cavity, and then I did IV infused chemo. I've done immunotherapy, I've done oral chemo’s, and next month I'll be doing some radiation for a little bit of cancer that's on my rib.

Some chemo’s make you nauseous. Not all of them do. Some chemo’s make you lose your hair. Not all of them do. What they all do seem to have in common is fatigue. The fatigue can be overwhelming at times, but the key to it is not to fight it. If you need to take a nap, take a nap. It's the best thing you could do for your body. Don't fight it. Enjoy the nap. There's nothing better than a nap.

Dr. Diane Reidy-Lagunes:

Amen to that. Nothing better than a nap. My patients say, “Sometimes I feel like just a wet mop,” and I think it's so powerful. I get it. The wind is completely out of the sails. Sheryl, any magic remedies for that fatigue?

Nurse Sheryl Scott:

Two things that help with that fatigue: drinking plenty of fluids. Being well hydrated. That is kind of like your rinse cycle for a patient and kind of helps rinse out the toxins, helps keep the patients very hydrated. And the second thing is some sort of purposeful exercise, whether it be initially starting out walking down the driveway to the mailbox, and then slowly, slowly building upon that can really help with that fatigue.

But I think Stacy's right. If you need a nap, you need a nap. Also, balance your activities because you don't want to be having a great day and fill it with all these activities because you will pay for it the next day, and then you'll be frustrated with that. So kind of balancing things can be helpful with that fatigue as well.

Dr. Diane Reidy-Lagunes:

Absolutely. Then we also have nausea, vomiting, diarrhea. I know you're very good at managing those. When do those typically start? When do you typically see those side effects for our patients?

Nurse Sheryl Scott:

So we tend to see them usually, if you're getting intravenous chemotherapy, we can see those start around day three. The drugs that we have for prevention of nausea are unbelievably good. It's pretty rare that we see vomiting related to chemotherapy anymore because the drugs themselves are categorized into the amount of nausea that they can cause. So then we have a plan of what types of anti-nausea medications we're going to give pre-chemo. Also, some patients may take them for a couple of days, two to four days maybe, after the treatment. And then we also send patients home with as-needed medications as well.

With nausea, food can be very helpful, almost like a morning sickness. In fact, there is a direct relationship for women as to how much morning sickness you had during pregnancy and how you'll tolerate chemo. And we always ask that question when we're assessing the patient in the beginning, because that helps us adjust things as needed.

Dr. Diane Reidy-Lagunes:

We could probably spend hours talking about all the various side effects that could potentially happen and how best to manage them, but today I really want to focus on those visible side effects because for many of our patients, they may want to be private about their illness and yet certain types of side effects are just telling the world, “I'm on chemotherapy.” And the number one concern for many of our patients is hair loss.

In fact, in 1950 there was a survey that went out that asked patients what was their biggest concern was when it came to treatment, and it was hair loss. And when that survey was repeated 60 years later, it was again, hair loss. And I think many of us clinicians worry about life-threatening infections and other things, but we should understand that hair loss is really hard for our patients because it's really like, “Yeah, I have cancer and you can see that.”

So Mario, I know this is something that you wrote extensively about in your book and in other articles, but what's the first advice you give to patients about hair loss, and how do we best approach that?

Dr. Mario Lacouture:

Thanks, Diane. Nothing has made me realize the importance of hair loss like the case of a young mother that I had as a patient many years ago that, when I asked her what upset her the most about her hair losses, it was because she didn't want her young children to see that she was losing her hair and worry that she would be sick. So since then, I've devoted my career, as well as many others, to a better understanding and treatment of hair loss.

With IV chemotherapies, in the past six or seven years, a new generation of treatments has been developed that now allow people to maintain the majority of their hair during chemotherapies that are given IV. These devices are located in your chemotherapy offices, and they are known as the scalp-cooling devices. Essentially what they do is they circulate a very cold liquid in a cap that the patient wears during their chemotherapy. And the thought is that that very cold cap shrinks the blood vessels in the scalp, preventing chemotherapy from reaching the hair follicles, and increases the survival of hair follicle cells.

The clinical studies on these devices have shown that between half to two-thirds of patients will retain an amount of hair in which they would not need a wig or any type of covering. So these devices are now implemented in hundreds of cancer centers across the country. So I would encourage you to discuss with your oncologist before starting any type of chemotherapy, whether there is an availability of these types of devices.

Dr. Diane Reidy-Lagunes:

And in fact, I would love to share something that one of my patients shared with us regarding scalp cooling. Let's take a listen.

Patient:

I’ve been a patient of Dr. Reidy since November 2020 when I was diagnosed with colon cancer at the age of 47. Throughout the past three years, I've been doing chemo. For the last year, I've also been cold capping as I was starting to shed a lot of hair. I have not told my children about my diagnosis. So it's important to me to try to keep my hair. The cold capping, I'm not going to sugarcoat it, it's pretty awful. It's uncomfortable, as you are basically sitting with a cap that freezes your head while you receive treatment. It also prolongs treatment significantly. It is a half hour before and an hour after treatment, so it's a lot of sitting and it's not super comfortable. But I will say it's working for me. The only side effect I have from it is a headache that day into the evening. It's gone by morning. So if you don't want to lose your hair or have everyone know that you are going through treatment, it is worth it.

Dr. Diane Reidy-Lagunes:

Yeah, I think there's so much in there that she shares, like you said, Mario, similar to your patient, she doesn't want the world to know, in particular her own family. And Sheryl, you have a lot of patients that do lose their hair. What do you share with them about cold capping, and in particular, I would love to hear about the cost and what exactly goes into scheduling the cold capping. As she said, it's a little longer, which can be a big deal in terms of timing and other things that happen in life.

Nurse Sheryl Scott:

Absolutely. We do offer cold capping at MSK. We use a company called Paxman. And that company has an outer cap and an inner cap that, like Dr. Lacouture said, has the fluid running through, bringing the temperature of the scalp down. We fit patients for this prior to the chemotherapy. We like to have like at least five days ahead of time. A prescription is written by the physician and sent then to Paxman and then they send the patient their own outer cap and inner cap. It’s a self-directed program where the patients are then able to watch videos to learn how to put the cap on. Your hair is wet with this, so the nurse will come out when it's time for you to come into the chemo unit and help you dampen the hair. A conditioner is put through it. The chemo nurse will check to make sure that it fits correctly, but it really is a self-directed program.

Dr. Diane Reidy-Lagunes:

And with certain therapies, it's not safe to do, right?

Nurse Sheryl Scott:

Correct.

Dr. Diane Reidy-Lagunes:

That's also important for our patients to know, that not all chemotherapies may be effective in preventing hair loss with the cold capping.

Nurse Sheryl Scott:

Correct. So that's why it's important to, if the nurse doesn't bring it up or the doctor doesn't bring it up, feel free to have a conversation about it. You want to be aware if that isn't an option for you. There are some side effects, like your patient had said. You can have a headache. You can have some nausea. Some patients will feel claustrophobic as well because of the fact that that cap is pretty tight, but we give medications to ease all of that as well.

Dr. Diane Reidy-Lagunes:

And does insurance pay for it?

Nurse Sheryl Scott:

So insurance doesn't always pay for it. They're getting better about it. It runs anywhere from $2,000 to $3,000 and then there is a rental fee for the actual machine of about $70 per treatment. We do give our patients a letter documenting all the studies as to why we feel this is necessary, including the psychological effects to the patient. The majority of patients have gotten some money back, not all.

There are other options though. Penguin is another company that is more self-directed. If a cancer center doesn’t have machines, that is something that you can order from their company. It's a little bit more work in the fact that you need to have a capper, and it's several caps, that are placed in dry ice. So it's a little bit more organization for the patients as far as obtaining the dry ice, bringing a big cooler in, and having someone that is able to do that. But that also is another option for cost effectiveness, as well as if that opportunity for scalp cooling is not available. That's another option.

Dr. Diane Reidy-Lagunes:

Got it. And Mario, any other options as a plan B? Shampoos or any types of products that may be able to at least mitigate the risk of hair loss or prevent some of the hair thinning?

Dr. Mario Lacouture:

I'm glad you asked because it's not only complete hair loss that can affect a person psychosocially and emotionally, but actually hair thinning can also have a significant impact. And a study we conducted some years ago by surveying patients, we found that the impact of hair thinning can be as significant as losing all of your hair, because people say it's so difficult to cover it, to hide it, and to find a way to conceal it.

So for people who have hair thinning, especially those that have thinning after they have completed their chemotherapy, or in the thousands of people who are receiving endocrine therapies for many years, there are treatments that are available orally as a tablet (minoxidil) or topically (you apply it onto your scalp). This is a drug that is already approved by the FDA. The topical version, the one you apply on the scalp is over the counter. Most people know it as Rogaine. So you apply this every night on the scalp, and it has shown to stimulate hair growth in people that have hair thinning as a result of certain types of cancer therapies.

In recent years, because of the difficulty – some people develop a little bit of itching on the scalp when they apply it – there has emerged a large amount of data showing that the administration of a tablet, a very low dose of oral minoxidil, is also effective in stimulating hair growth. We have found that this is even more effective than the topical version. So I've treated many, many people with the oral minoxidil and they have shown, through the use of this medication daily, that the hair grows up to 20% in a matter of about three to six months. 

And in addition to that, other topical tools that may be effective, although not as much, as the minoxidil are certain shampoos. For example, there is an antifungal shampoo that is called Ketoconazole, and this shampoo also has an anti-androgen effect. In other words, it blocks the hormone that is normally present in high amounts in men. This is the hormone that causes most men to lose their hair. So if we block this locally in the scalp, the thought is – and it has been found in smaller studies of women with hair loss – that more hair will grow. So in general, this is dual treatment with the minoxidil and the topical shampoo that we would employ in cases where people have hair thinning.

Dr. Diane Reidy-Lagunes:

Beautiful. Anything in the diet that you recommend?

Dr. Mario Lacouture:

I do check a variety of micronutrients in the blood for those people that do not respond initially to the minoxidil. And I have found that up to one out of 10 people have a deficiency in either zinc or vitamin D. So I think if you do not respond to treatment, it is important to check those micronutrients, as they are easy to replenish.

Dr. Diane Reidy-Lagunes:

And just a word on radiation and hair loss. Most of the therapies that we're talking about now that cause generalized hair loss or hair thinning is because it goes everywhere. But radiation may be a little bit different. Any advice for patients that undergo radiation therapy to, for example, the brain where it may affect the scalp?

Dr. Mario Lacouture:

This can be very impactful because it is much more difficult to treat. However, we have found that with the use of the minoxidil, we improve about 20 to 30% of people in terms of their growth, so not a really striking amount of people. So I really think there is an urgent need to better understand this type of hair loss in order to better prevent it.

Dr. Diane Reidy-Lagunes:

Can it grow back?

Dr. Mario Lacouture:

Most of the studies have shown that it is dependent on the dose of the radiation. So what I recommend to people is to talk to their radiation oncologist. And radiation oncologists are wonderful at thinking about what type of side effects you will be developing and informing you ahead of time, because knowing ahead of time before something happens is going to make it much more tolerable than if you are taken by surprise.

Dr. Diane Reidy-Lagunes:

And Sheryl, Mario alluded to the fact that the psychological impact of hair loss can be really overwhelming for men and women, and that also includes potentially eyebrows or eyelashes. Any words of wisdom to share with patients that have such anxiety about this potentially happening to them?

Nurse Sheryl Scott:

There are programs out there through the American Cancer Society called, “Look Good, Feel Better.” There are lots of products out there for eyebrows, eyelashes. And this “Look Good, Feel Better” kind of helps patients learn how to use these products. So that's something that I tend to recommend for a lot of our patients.

Dr. Lacouture could probably speak better about this, but we tend to see eyebrows and eyelashes come back first. We tell patients to look for that. That means that the hair is on its way, so to speak. And that can be a little helpful as well, so that they start to see, because they all have this fear that it's not going to come back and I totally understand where that's coming from.

Dr. Diane Reidy-Lagunes:

Of course. Mario, let's switch to the skin, another very visible side effect. Many of my patients, they would say they'd rather have hair loss than some of the skin rashes. Can you explain a little bit more about some of the skin side effects that you deal with day in and day out, and your approach to that?

Dr. Mario Lacouture:

The rash that occurs secondary to these targeted therapies can occur on up to 90% of patients. There are actually two pieces of good news regarding this rash: there are treatments that have been shown to reduce the incidence of this rash by more than 50%. And they consist of an inexpensive oral antibiotic that is to be taken preventively during the first two to three months of therapy.

The other positive aspect about this is that the rash will not last the whole duration of treatment. It will peak within the first month and then slowly taper down. And not only that, but people who developed this rash appear to have a better response in terms of the anti-cancer effect of their drug.

Dr. Diane Reidy-Lagunes:

Any additional creams, over the counter or otherwise, that patients with skin rashes should use?

Dr. Mario Lacouture:

Dry skin and itchy skin are probably one of the most common complaints or most common side effects that people have when I see them. And dry skin is not a matter of drinking more water only. Dry skin is also from the environment, and in these instances, it's something that you just cannot control. It's the cancer drug that is doing this because it also targets the skin. 

So it is important to use fragrance-free products that are available over the counter. It’s important to use large amounts over all body areas and applied after the shower. We usually recommend people to use fragrance-free soaps in the shower and fragrance-free detergents to wash their clothes. In the wintertime, they should have a humidifier in their homes to increase the surface temperature.

And when choosing a moisturizer, it is very important to pick a vehicle of the moisturizer that works with you. For example, moisturizers are available in three main vehicles. The first one is the ointment. These are the best moisturizers, but they are very thick and greasy, so a lot of people do not like them. These are usually the ones that come in tubs like Vaseline. We have creams. Creams are usually the white products that come usually in a tube, and these you can spread more easily over the body and are good moisturizers to apply over moderate surface areas. And then lotions, whereas they are not the best of all moisturizers, they are the moisturizers that are easier to apply over large areas of the body, and these usually will come in a bottle with a pump.

Importantly, moisturizers that are over the counter, for those of you that may have very dry and scaly skin, should contain certain ingredients that allow for that dead skin to fall off and to retain the new skin underneath. These ingredients include ammonium lactate or salicylic acid.

Dr. Diane Reidy-Lagunes:

Let's switch to the nails because the nail part can be brutal, not only annoying but also quite painful. Any words of advice on patients that may get that so-called paronychia, the little cuts around the nails and the brittle nails?

Dr. Mario Lacouture:

It's important to remember that every one of us carries a lot of bacteria under our nails, so anything that will inflame the tips of our fingers can result in secondary infections. So one of my most important recommendations for people is that if they are receiving a therapy that is resulting in this to wash their hands with an antibacterial soap, or even better, with a soap called Chlorhexidine, which is that same pink soap that is used when you are undergoing any surgical procedure.

In addition to that, if the nails lift and they are painful and discharging, we also recommend a very old inexpensive remedy, which is to soak the nails in a solution of white vinegar and water. And then finally, if this doesn't help, it is important to see a dermatologist or to see your oncology nurse, as a bacterial culture of the nails should be obtained to determine what antibiotic to use.

Dr. Diane Reidy-Lagunes:

Sheryl and Mario, thank you so much for joining us today and for sharing your wisdom. I learned a tremendous amount from both of you. 

Nurse Sheryl Scott:

Thank you so much for having us.

Dr. Mario Lacouture:

Wonderful to be here.

Dr. Diane Reidy-Lagunes:

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us your questions, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing it on Apple Podcasts or wherever you listen. Any products mentioned on the show are not official endorsements by Memorial Sloan Kettering. Disclosure: Dr. Lacouture has received research support from Paxman. These episodes are for you but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Reidy-Lagunes. Onward and upward.