Controlling Symptoms Q&A's

The degree of tiredness and the time it lasts for after treatment has finished varies a great deal from person to person. Also different types of radiotherapy cause different levels of fatigue.

To some extent age has an effect as well. Research has suggested that people under 40 will recover quite quickly from the effects of radiotherapy whereas for those over the age of forty recovery may take much longer. Indeed for some people there will always be some slight loss of energy following treatment. This usually takes the form of a loss of stamina rather than actual tiredness, so that day to day activities are not affected but when you try to do something particularly strenuous you might find that you were not able to do quite so much as you could before you had the chemotherapy.

Usually people notice a great improvement in their tiredness within one to two months of completing treatment and most people would be back to normal, at least for everyday activities, by about three to four months. But these are only average figures and your age and the precise type of treatment you have might mean that it could take a little longer for you to fully recover.

Sometimes other things can also cause of the tiredness. If you are feeling particularly low and miserable then you may have developed depression, which can make any tendency to tiredness much worse (depression is a recognised side-effect of radiotherapy, although it is relatively uncommon). Depression can usually be easily and effectively treated, so do mention it to your doctors and nurses if you think might be depressed.

Anaemia is another common cause of tiredness in this situation and the feeling of fatigue is often accompanied by other symptoms such as breathlessness and light-headedness. Anaemia has recently been shown to be a bigger cause of tiredness during radiotherapy than was previously thought. It has now been shown that even slight anaemia can cause considerable tiredness. This can easily be put right with a blood transfusion. In the past doctors usually only suggested a blood transfusion if anaemia was quite severe but transfusions are being increasingly used to treat milder anaemia, leading to a great improvement in symptoms.

So if your tiredness is continuing and is causing you problems and affecting your quality of life do mention this to the doctors and nurses when you go for a check-up (or if you don't have a check up in the near future ask for one). They will be able to tell you whether or not the symptoms you are experiencing are normal after the treatment you have had. They will also be able to make sure there is no other cause for the tiredness. Finally they will be able to give you advice on how to cope with the tiredness while life is getting back to normal.

The degree of tiredness and the time it lasts for after treatment has finished varies a great deal from person to person. Also different types of chemotherapy cause different levels of fatigue.

To some extent age has an effect as well. Research has suggested that people under 40 will recover quite quickly from the effects of chemotherapy whereas for those over the age of forty recovery may take much longer. Indeed for some people there will always be some loss of energy following treatment. This usually takes the form of a loss of stamina rather than actual tiredness, so that day to day activities are not affected but when you try to do something particularly strenuous you might find that you were not able to do quite so much as you could before you had the chemotherapy.

Usually people notice a great improvement in their tiredness within three months of completing treatment and most people would be back to normal, at least for everyday activities, by about six months. But these are only average figures and your age and the precise type of treatment you have might mean that it could take a little longer for you to fully recover.

If you are feeling particularly low and miserable then you may have developed depression, which can make any tendency to tiredness much worse. Depression can usually be easily and effectively treated, so do mention it to your doctors and nurses if you think might be depressed.

Anaemia is another common cause of tiredness in this situation and the feeling of fatigue is often accompanied by other symptoms such as breathlessness and light-headedness. Anaemia has recently been shown to be a bigger cause of tiredness during chemotherapy than was previously thought. It has now been shown that even slight anaemia can cause considerable tiredness. This can easily be put right with a blood transfusion. In the past doctors usually only suggested a blood transfusion if anaemia was quite severe but transfusions are being increasingly used to treat milder anaemia, leading to a great improvement in symptoms.

3. Brain tumours, like most cancers, are usually covered by a rim of inflammation, where the tumour meets the surrounding normal tissue. This area of inflammation is found with both primary brain tumours (those which start off in the brain) and secondary tumours which have spread to the brain from a cancer elsewhere in the body.

The layer of inflammatory tissue makes the tumour seem larger than it actually is. It also causes pressure on the surrounding normal tissue. Because the brain fits quite tightly into the bony framework of the skull this means that the normal tissue is squeezed between the swelling caused by the tumour and inflammation and the rigid structure of the skull. The pressure this causes on the normal brain tissue leads to unpleasant symptoms like headache and sickness.

Steroids are drugs which can reduce inflammation in the body. One steroid in particular, called dexamethasone, is very effective in easing the inflammation caused by brain tumours.

Taking dexamethasone tablets can shrink the area of inflamed tissue surrounding tumours in the brain. This reduces the volume of abnormal tissue and so eases pressure and relieves symptoms.

Unfortunately dexamethasone does not have any effect on the cancer itself and so the benefit that it gives is only temporary. But very often taking dexamethsaone can give a very valuable respite from problems like headache and sickness for some weeks or even months. In addition the steroid does have other benefits, like increasing appetite and energy levels, which can lead to an overall improvement in quality of life.

1. Lymphoedema develops in the arm when the drainage of lymph fluid from the tissues in the arm is impaired, causing lymph fluid to accumulate in those tissues, which makes the arm swell. The lymph drainage, through the lymph glands under the arm, can be affected either by removal of glands at operation or sometimes by scarring, caused by radiotherapy or surgery, or by the presence of tumour in the glands.

Once the lymph drainage has been damaged it never completely goes back to normal so it is unusual to get rid of all traces of lymphoedemBut a variety of things can be done to help reduce and control the swelling. These include:

good skin care: gently moisturising the skin each day with a non-perfumed cream or oil and avoiding any risk of infections in the arm (from cuts, burns etc).

compression garments: these are stretchy sleeves which gently squeeze the swollen tissues, preventing fluid from building up and giving the muscles support. They do need to be expertly measured and fitted. Sometimes if there is a lot of swelling special multi-layered bandages will be used at first, to reduce the swelling sufficiently for a sleeve to be fitted.

limb positioning: gravity affects the amount of swelling in the arm. If you can keep your arm up on a cushion when sitting down, or slightly elevated on a pillow in bed at night this will help. Also avoid carrying heavy shopping or other loads with your affected arm.

exercises: gentle exercises will help your muscles to work with the compression sleeve to move fluid out of the arm. n massage: this is an important part of treatment for lymhpoedema and there are several techniques, so you do need specialist advice.

compression pumps: these are only occasionally used and are electrically powered to gently squeeze the arm and help to move the fluid n for those people whose lymphoedema is caused by tumour in their lymph glands then further treatment with chemotherapy or hormones may well help to ease the problem.

As you can see, although a lot can be done the treatment of lymphoedema needs special skills and expert help. In most hospitals that treat breast cancer either the Breast Care Nurses are trained to give advice or, often, there are special Lymphoedema Clinics with Nurse Practitioners who specialise in managing the problem. So do have a word with your local breast cancer team and they will ensure you get to see the right person to help you.

Lymphoedema develops in the arm when the drainage of lymph fluid from the tissues in the arm is impaired, causing lymph fluid to accumulate in those tissues, which makes the arm swell. The lymph drainage, through the lymph glands under the arm, can be affected either by removal of glands at operation or sometimes by scarring, caused by radiotherapy or surgery, or by the presence of tumour in the glands.

good skin care: gently moisturising the skin each day with a non-perfumed cream or oil and avoiding any risk of infections in the arm (from cuts, burns etc).

Usually when lymphoedema develops after treatment for a breast cancer it is due to either previous surgery or previous radiotherapy (or a combination of the two). Only very occasionally is it actually a sign of the cancer coming back.

Lymphoedema due to scarring, or damage, to the glands as a result of treatment usually appears later. Sometimes it will be some years before it begins to become apparent.

It is very unlikely then that the lymphoedema you have noticed is a sign of the cancer coming back. But you should see your doctor to get this checked: partly to make sure that there is no cancer there but also because a lot can be done to control the lymphoedema and reduce the chances of it becoming a problem.

3. Yes, it is perfectly safe for you to have acupuncture although, as you have realised, it is best to avoid any needles in your affected arm.

You are right, however, to recognise that you do need to take good care of the skin of your affected arm. Things like gently moisturising the skin each day with a non-perfumed cream or oil and avoiding any risk of infections in the arm (from cuts, burns etc) will help reduce any likelihood of increasing the lymphoedema and so are wise precautions.

4. With breast cancer treatment in the past it was common for surgeons to try and take away as many lymph nodes as possible from under the arm and for this to be followed by radiotherapy to the remainder of the breast (or the wall of the chest, if a mastectomy had been performed) AND the tissues under the arm (the axilla). This very often led to swelling of the arm (lymphoedema).

It is now recognised that if the surgeon clears most of the glands from under the arm then radiotherapy to the axilla is not necessary. National guidelines from the Royal College of Radiologists say that if more than 10 lymph glands have been removed from under the arm then radiotherapy to the axilla is not needed, even if some of the glands contained seedlings of tumour. The only exception to this is if there are signs that there was tumour in the glands which has actually broken through the capsule to the lymph nodes and started to spread into the surrounding fatty tissues, in this case radiotherapy is still recommended - but this is very uncommon.

There is still a risk that some swelling of the arm might develop following an axillary clearance but the chances of this happening should be less than 1 in 20 and this is much less than used to be the case when both surgery and radiotherapy were used.

1. Morphine is invaluable in the management of severe pain for many people. Both patients and doctors are sometimes anxious about using morphine so it is important to be aware that, when used to treat severe pain, morphine is not addictive, it does not shorten life-expectancy and is safe if the dose is matched to the pain. This last point is really the answer to your question in that the correct dose of morphine is the dose that gets rid of the pain. The actual dose needed to do this varies tremendously from patient to patient. The dose should always therefore be matched against the needs of the individual. This means that there is no actual upper limit to the dose that can be given.

Morphine does have side-effects. Two which are common are constipation and nausea and with higher doses of the morphine additional drugs to relieve or prevent these symptoms may be needed.

Provided higher-doses of morphine produce better pain control, without undue side-effects, then the dose can be increased progressively. But it is essential that this increase should be carefully monitored by your medical team.

2. The TENS machine is a device for transmitting electrical energy through the skin to the nerves, to try and relieve pain. The initials TENS stand for transcutaneous electrical nerve stimulation.

There are a number of different types of TENS machines, some are quite large whilst others are small and portable, but all work on the same principle. They all use electricity, from the mains or from batteries, to produce electrical impulses which pass through wires to two electrodes placed on the skin. The electrodes are silicone rubber pads containing fine particles of carbon which transmit the impulse to the skin.

The treatment itself is painless and may last anywhere from a few minutes to hours and can be continued for as long as it is helpful (although there is tendency for the treatment to become less effective after several months).

The benefit is often not immediate and it may take some days to find the most effective position for the electrodes. When the treatment does work people often say that it changes the pain to a much more comfortable sensation of buzzing or humming TENS machines are not suitable for some people with heart pacemakers. It has also been said that they are less effective for people taking morphine or other strong pain killers but this is not universally true.

There are differing reports about the value of TENS machines in controlling cancer pain. Some doctors have said they don't think they help whilst others claim they are very useful. For people who do have pain from cancer that is not well controlled with other treatments it is always worthwhile discussing it with their doctors to see whether they think a TENS machine could help.

3. The leaves and buds of the cannabis plant have been used in herbal remedies for over 3000 years for conditions as varied as malaria and constipation. In the Middle Ages cannabis was used as a pain killer, particularly for rheumatic pain.

In recent years more some 66 different active chemicals have been identified in the cannabis, marijuana, plant and these are called cannabinoids. In the UK a synthetic, man made, version of one of these cannabinoids is available on prescription as a drug called Nabilone (although the use of cannabis, or marijuana, in its natural form remains illegal).

Cannabis does have some analgesic (pain killing) effect and at least 5 clinical trials have been carried out comparing cannabis or cannabinoid drugs with more conventional pain killers for people who have pain due to a cancer. These have shown that the pain killing benefit of cannabis or cannabinoids is no better than ordinary codeine (a widely used analgesic, available on prescription or as an ingredient in many over the counter pain killers).

Whilst this means that cannabis, or cannabinoids, might help ease mild or moderate (but not severe) pain their side effects make them undesirable. These include sedation, confusion, altered perception of time and space, low blood pressure and palpitations. Marijuana also contains chemicals which can cause cancer (carcinogens) and smoking the drug can cause respiratory problems. The cannabinoid drugs also share a number of these side effects.

So because there are many other pain killers which are just as, if not more, effective and because of the side effects they cause, neither cannabis nor cannabis extracts are recommended as a treatment for pain control.

The leaves and buds of the cannabis plant have been used in herbal remedies for over 3000 years for conditions as varied as malaria and constipation. In the Middle Ages cannabis was used as a pain killer, particularly for rheumatic pain.

4. It may seem surprising but although doctors have known for more than fifty years that radiotherapy can often relieve the pain caused by secondary bone cancer, the way in which the treatment actually works is still not understood.

Often x-rays and scan tests will show some reduction in tumour seedlings, and healing of the damaged bone, in the months after radiotherapy. But equally often those same tests will show no change at all, even when there has been excellent pain relief.

Despite the uncertainty about how it works the evidence for the value of radiotherapy in this situation is overwhelming. Overall about seven out of ten people get good pain relief, and of those about three out ten get complete freedom from pain. The improvement is not immediate, taking 7 to 10 days after treatment to become apparent and then sometimes as long as 4 to 6 weeks to get the full benefit. Some people find the treatment gives permanent pain relief but on average the improvement lasts about 3 to 4 months, but the treatment can often be repeated if the pain does come back.

5. Unfortunately people with cancer do have to pay a prescription charge for their prescriptions unless they fall into one of the groups of people that the government has decided are exempt from charges and who do not have to pay. These groups are:

you have one of a small number of 'permanent' medical conditions, these include some types of diabetes and an under-active thyroid gland (hypothyroidism or myxoedema)

it is worth him having a word with his family doctor to ask if they can give him a fairly long supply of the drug each time (obviously if they only give him a week's supply of the drug on each prescription then this will be much more expensive for him than if they were to give him a month's supply)

if he needs lots of prescriptions he may be better off getting a 'prepayment certificate'. This is like a season ticket and gives you all your prescriptions 'free' for a period of either four months or twelve months. The cost of a 4 month certificate is currently £32.40 and that of a 12 month certificate is £89.00

You can find out all the details of the rules on treatment charges by contacting the Department of Health Publications, PO Box 777, London SE1 6XH (e-mail: [email protected]) and asking for leaflet HC11: help with health costs. This is also on the Department of Health website at www.doh.gov.uk/nhscharges/hc11.htm. Copies should also be available at major post offices, your local Social Security office or your family doctor's surgery.

Many people, including some politicians and MPs do feel that it is unfair that cancer patients have to pay for their prescription drugs. There have been campaigns to try and change these rules but so far they have been unsuccessful. If you feel strongly about this then you could write to your local MP to let them know your views. (UK)

Unfortunately people with cancer do have to pay a prescription charge for their prescriptions unless they fall into one of the groups of people that the government has decided are exempt from charges and who do not have to pay. These groups are:

you have one of a small number of 'permanent' medical conditions, these include some types of diabetes and an under-active thyroid gland (hypothyroidism or myxoedema)

6. Brain tumours, like most cancers, are usually covered by a rim of inflammation, where the tumour meets the surrounding normal tissue. This area of inflammation is found with both primary brain tumours (those which start off in the brain) and secondary tumours which have spread to the brain from a cancer elsewhere in the body.

Steroids are drugs which can reduce inflammation in the body. One steroid in particular, called dexamethasone, is very effective in easing the inflammation caused by brain tumours.

Taking dexamethasone tablets can shrink the area of inflamed tissue surrounding tumours in the brain. This reduces the volume of abnormal tissue and so eases pressure and relieves symptoms.

I am going to have chemotherapy for cancer and am worried about the risks of sickness. A friend has said cannabis can stop nausea and vomiting during chemotherapy. Is this true?

The leaves and buds of the cannabis plant have been used in herbal remedies for over 3000 years for conditions as varied as malaria and constipation. In recent years more some 66 different active chemicals have been identified in the cannabis plant and these are called cannabinoids.In the UK a synthetic, man made, version of one of these cannabinoids is available on prescription as a drug called Nabilone (although the use of cannabis, or marijuana, in its natural form remains illegal).

Over the last 20 years many clinical trials have been carried out comparing cannabis or cannabinoid drugs with more conventional anti-sickness drugs for people having cancer chemotherapy.

These trials have shown that both cannabis and cannabinoids do have an effect in reducing nausea and vomiting during chemotherapy. This activity appears to be similar to the best of the anti-sickness drugs that were available up until about 1990. But during the 1990s a new type of anti-sickness drug became available - the serotonin, or 5HT3, antagonist. Examples of 5HT3 antagonists available in the UK include ondansetron (Zofran), granisetron (Kytril) and tropsietron (Navoban). These drugs proved to be much more effective than any of the previous anti-sickness drugs, include cannabinoids, in controlling or preventing chemotherapy-induced nausea and vomiting.

Cannabis itself does have side effects including sedation, confusion, altered perception of time and space, low blood pressure and palpitations. Marijuana also contains chemicals which can cause cancer (carcinogens) and smoking the drug can cause respiratory problems. The cannabinoid drugs also share a number of these side effects. Although during the 1980s there was some enthusiasm for using cannabinoid drugs to help control chemotherapy related sickness the development of the much more powerful 5HT3 antagonists during the 1990s and the side effects caused by the cannabinoids mean that they are now very rarely used.

1. All though all of us get hiccups from time to time they can occasionally be a real problem for some people with more advanced cancers, with episodes lasting for days at a time.

There are many different causes for hiccups in this situation but by far the commonest is stretching or irritation of the stomach (gastric distension).

There are a whole range of 'folk' remedies for hiccup which are worth trying, because although some of them may seem odd they all actually work in one way or another to help switch off the nerve reflex which is causing the problem. These simple 'treatments' include:

If none of these help then, since stomach irritation is usually the cause of the hiccups, trying a simple 'over the counter' medicine like peppermint water or antacids containing charcoal (your pharmacist will be able to advise you about these) may well bring relief.

If the hiccups continue to be a problem then there are some more 'medical' treatments that can be used, so do get advice from your doctors and nurses. These other treatments include various simple and safe drugs which often help or 'mechanical' remedies like using cotton buds or a soft catheter to stimulate the soft palate or the back of the throat. Drug treatments your doctor may recommend include an anti-sickness drug called metoclopramide, small doses of a blood pressure medicine called nifedipine, a muscle relaxant known as baclofen, a sedative called Largactil or high doses of an antibiotic, Erythromycin.

All though all of us get hiccups from time to time they can occasionally be a real problem for some people with more advanced cancers, with episodes lasting for days at a time.

There are many different causes for hiccups in this situation but by far the commonest is stretching or irritation of the stomach (gastric distension).

2. Excessive or profuse sweating can often be a troublesome problem for people with cancer. There are a number of different causes for these sweating episodes. These include:

the cancer itself: some types of cancer do often cause drenching sweats, which often tend to be worse at night. These are most common with lymphomas (non-Hodgkin's lymphoma and Hodgkin's disease), carcinoid tumours and also when a secondary cancer has spread to involve the liver.

some drugs increase the chance of sweating attacks. These include morphine-based painkillers, some anti-depressant tablets and a number of hormone preparations commonly used in the treatment of breast and prostate cancer (like tamoxifen, Arimidex (anastrozole) and Zoladex (goserelin)).

Although one or more of these may help do let your doctors and nurses know if sweating attacks are a problem because they may be able to help in a number of ways. For example:

if sweating attacks are a feature of the type of cancer you are being treated for then they can explain this and let you know if the attacks are likely to disappear as the treatment continues

if the underlying cancer is the problem then even if things have reached the stage when further treatment to control the tumour is not possible there are still drugs that can be prescribed that will often reduce or stop the sweating attacks (these include steroids and some anti-inflammatory tablets)

if there is an underlying infection contributing to the sweats then they will be able to give you the appropriate antibiotics to get rid of this

3. Itching of the skin is quite a common problem for people with cancer, especially in the more advanced stages of the illness. There are a number of causes for this sort of itching and these include:

the underlying cancer itself may be the cause, especially in lymphomas (non-Hodgkin's lymphoma and Hodgkin's disease), carcinoid tumours and stomach cancer

Do talk to your doctors and nurses if itching is a problem because there are a number of ways in which they may be able to help. For instance:

they can advise on soothing lotions or creams that may help relieve the irritation (thinks like calamine lotion, menthol cream, crotamiton (Eurax) cream or mild steroid creams). - they can prescribe drugs like steroids, antihistamines or non-steroidal anti-inflammatory tablets - although usually using the other measures already mentioned will often ease the problem and drugs will not be needed.

4. Brain tumours, like most cancers, are usually covered by a rim of inflammation, where the tumour meets the surrounding normal tissue. This area of inflammation is found with both primary brain tumours (those which start off in the brain) and secondary tumours which have spread to the brain from a cancer elsewhere in the body.

Steroids are drugs which can reduce inflammation in the body. One steroid in particular, called dexamethasone, is very effective in easing the inflammation caused by brain tumours.

Taking dexamethasone tablets can shrink the area of inflamed tissue surrounding tumours in the brain. This reduces the volume of abnormal tissue and so eases pressure and relieves symptoms.