Your Guide for the Cancer Journey: Cancer and its treatment

This chapter offers some tips that might help prevent or manage particular side effects. Given the wide range of cancers and treatments, and because individual susceptibility varies from person to person, these are only general tips. Any advice that your cancer team offers overrides these suggestions. If you feel unwell at any time, contact your GP or cancer team. Many of these tips are also covered in my book The Holistic Guide for Cancer Survivors, which places a greater emphasis on the role of CAMs in combination with conventional medicine.

Nausea and vomiting are among the most feared and distressing side effects of chemotherapy and certain malignancies. Unfortunately, they are also relatively common: between 1 in 10 and 1 in 4 people receiving chemotherapy endures persistent nausea and vomiting, for example.82 Furthermore, at least 7 in every 10 people with advanced cancer report chronic nausea.83 Some cancers cause nausea and vomiting by, for example, affecting the gastrointestinal tract or changing the blood’s chemistry.

The likelihood of developing nausea and vomiting depends on the drug and the patient. Cisplatin and mustine, for instance, commonly cause vomiting. Vinca alkaloids, in contrast, rarely trigger nausea. Certain people – such as women, younger people and those who have been sick previously with chemotherapy – are at especially high risk of developing nausea and vomiting.2

Interestingly, the more you expect – based on what you have heard or on previous experience – to develop nausea and vomiting when you receive chemotherapy, the more likely the symptoms are to occur.82 Nausea and vomiting – which evolved to expel hazardous material before it can do you harm – are among our body’s strongest and most basic reactions. Occasionally, even the thought or a reminder (‘cues’) of the chemotherapy is enough to trigger the reaction – so-called anticipatory nausea and vomiting. Doxorubicin, for instance, is a red-coloured infusion that commonly causes nausea and vomiting. Some patients, therefore, experience nausea and vomiting when they see the colour red outside the chemotherapy suite.82 Counselling and hypnosis can help break any psychological link between anticipatory cues and nausea and vomiting.

Anti-emetics are drugs that reduce the frequency and severity of nausea and vomiting. Your cancer team might suggest that you take anti-emetics – which include ondansetron, granisetron and aprepitant – before and for 24–48 hours after chemotherapy. You might receive additional treatment if you develop ‘breakthrough’ nausea and vomiting during chemotherapy or ‘late’ nausea and vomiting, which is when it occurs 3–5 days following chemotherapy.3 Radiotherapy can also cause vomiting in the minutes or hours after treatment begins. Again, anti-emetics can help reduce the frequency and severity of the nausea and vomiting.3

The self-help tips listed below might also help to prevent nausea and vomiting.3, 82, 84, 85

•Avoid fatty, greasy and fried foods. Eat small amounts of plain foods when you feel able, such as:

•Dry foods, such as toast and crackers, might help settle a sensitive stomach. Some people find that dry foods work best if eaten in the morning.

•For centuries, traditional healers have used ginger to alleviate nausea from a variety of causes. Try crystallized ginger, ginger tea or ginger biscuits.

•Vomiting can lead rapidly to dehydration, so sip plenty of drinks – such as ginger beer, mineral water, lemonade or soda water – slowly through a straw. If you find a straw difficult to use, try a bottle with a sports cap.

•Rinse your mouth before and after meals, which helps get rid of any lingering tastes.

•Sit up or lie back with your head raised for at least an hour after eating rather than lie down.

•Relaxation techniques – such as meditation and mindfulness – can help reduce nausea and vomiting before eating.

Several factors can trigger constipation in people with cancer, including some painkillers, certain drugs used to treat nausea and vomiting, dehydration and several malignancies.3 If you think you have constipation, record how many times you pass a bowel movement and the consistency. Ideally, use the Bristol Stool Chart, which is widely used by doctors and nurses (<www.hct.nhs.uk/media/1067/bristol-stool-chart.pdf >) to describe this. Do not take laxatives – even those bought without a prescription – unless your cancer team tells you to. Seek medical advice if the constipation is severe or painful or you are worried.

•Dehydration can make stools harder, so drink between six and ten glasses of fluid a day. This can include water, prune and other fruit juices, lemon squash, fizzy drinks and soup. Some people find that not drinking alcohol, coffee, tea and grapefruit juices, which can make you urinate more, helps prevent dehydration.

•Try to have regular bowel movements. You might find defecating after breakfast easier than at other times as this is when the bowel’s contractions tend to be strongest. Try to go to the toilet at the same time each day, which helps establish a routine.

Usually diarrhoea triggered by chemotherapy is mild and manageable with lifestyle changes and antidiarrhoeal drugs. Occasionally, however, diarrhoea is more serious. Indeed, the chemotherapy drug irinotecan can cause severe, even life-threatening diarrhoea.3 Always tell your cancer team if you experience severe diarrhoea. You should also contact your doctor urgently if you develop a fever and abdominal pain alongside the diarrhoea. This might indicate a potentially serious infection of the wall of the large bowel.3

People undergoing radiotherapy might find that they pass stools more often, the stools might be softer and there might be colicky pain or wind. This can develop into diarrhoea, which can be accompanied by mucus (‘slime’) or small amounts of blood.3 Again, ask your cancer team what to expect and speak to them if you are worried.

Sometimes doctors might prescribe – or advise you to buy – antidiarrhoeal drugs, such as loperamide. They may suggest you keep this at home and start taking the drug at the first sign of diarrhoea. Otherwise, however, never buy or use a treatment for diarrhoea – or any other symptom – without speaking to your cancer team first: some antidiarrhoeal drugs could cause additional difficulties or interact with other elements of your treatment.

The tips listed below might help alleviate diarrhoea without the need to take something for it. 3, 85–87

•Avoid high-fibre, fatty, greasy and spicy foods. Try eating plain food – such as bananas, white bread, white fish, chicken or turkey – in small, frequent meals.

•Eat foods rich in pectin, which is the natural gelling agent found in ripe fruit used to make jams and jellies. Eating less fibre and more pectin-rich foods helps build stool consistency (see Table 9.1).

•Diarrhoea may mean that you lose large amounts of a mineral called potassium, which nerves and muscles, for instance, need to work properly. Losing large amounts of potassium can leave you feeling weak and fatigued. Eating foods high in potassium helps replenish your stores of this vital mineral (see Table 9.1).

•Diarrhoea can lead rapidly to dehydration, so drink at least 2–3 litres a day, including water, lemon squash, fizzy or still drinks and clear soups or drinks made from beef stock cubes or extract. Some people find that avoiding caffeine, alcohol, fruit juices and smoothies helps alleviate diarrhoea, but make sure you get enough fluid in other ways.

•Probiotics help restore the natural balance of bacteria in your gut, which can become disrupted by cancer and its treatment as well as by supportive care, such as antibiotics. Changes to the balance of bacteria in the gut can trigger diarrhoea. Ask your cancer team or dietician if you are not sure which probiotic is right for you.

•Try eating foods at room temperature: cold and hot foods tend to stimulate the gut.

•Good hygiene is very important if you develop diarrhoea. Clean yourself carefully after each bowel movement. Use soft wipes and pat rather than rub. You can apply a barrier cream to protect the delicate area around the anus. Ask your cancer team or a pharmacist if you are not sure which barrier cream to use.

Some people with cancer experience difficulties urinating, either because of a cancer or its treatment. Radiotherapy, for example, can damage the bladder, causing symptoms that include pain on passing urine, increased frequency and blood in the urine. In general, bladder symptoms emerge during or soon after radiotherapy, but they might emerge up to a year after treatment ends. Your cancer team will rule out infections, which can also cause bladder symptoms.3

If you develop bladder symptoms, ensure that you drink sufficient fluids. Some people find taking cranberry capsules helps.3 If these do not improve the symptoms, your cancer team can prescribe several drugs that might restore bladder control.

Fatigue is one of the most disabling and distressing symptoms experienced by people with cancer. People with cancer-related fatigue feel tired all the time and physically, emotionally and mentally exhausted. Rest and sleep do not alleviate their profound tiredness. The body, especially arms and legs, might feel heavy. People might experience difficulty concentrating or cannot think clearly. Indeed, some people with severe cancer-related fatigue might be unable to perform everyday activities, such as eating, shopping, working, exercising or even personal hygiene.12

Preventing dehydration

Anyone, whether or not they have cancer, can easily become dehydrated as they go about their daily lives. Even in healthy people, the mild dehydration that might arise during our daily activities can cause a range of symptoms, including:88, 89

•constipation

•poor concentration and memory

•increased tension or anxiety

•fatigue

•headache.

Some people with cancer have additional issues that make dehydration more likely. You might experience difficulties swallowing, for example. You might feel too fatigued to get yourself a drink. You might lose fluids because of diarrhoea or vomiting. Whatever the cause, everyone should stay hydrated.

The NHS suggests that adults should drink 1.2 litres (six to eight glasses of water) each day to replace fluids lost in urine, sweat and so on. This is, however, an average: personally, I need to drink more than this. (Excessive thirst and increased urination might be a sign of diabetes, however, so see your GP if you experience these symptoms.) If you feel thirsty for long periods, you are not drinking enough. You should drink more during exercise, hot weather or when you are in a warm ward or chemotherapy suite. You should also drink more if you feel lightheaded, pass dark-coloured urine or have not passed urine for six hours.

Self-help tips for bladder symptoms

The tips listed below might help you to ensure you get enough fluids.

•Carry a water bottle with you and take sips throughout the day. Some nutritional supplements are sipped between meals, which can also help keep you hydrated. Ask your cancer team to speak to a dietician if you think this will help.

•If you are too fatigued to get up regularly, make sure you keep plenty of bottles of water by your chair or bed.

•Choose recipes with plenty of gravy, sauces, custards and cream. Keeping food moist can also help you if you have difficulties swallowing.

•Try different drinks – such as malted milk drinks or beef extracts, milk shakes, soups – provided these do not dull your appetite for meals. These can also boost your intake of protein, energy and other nutrients if eating enough food at mealtimes is difficult.

•Although you need to drink regularly, try not to consume too much during meals. Fluids can make you feel full up sooner and blunt your appetite.

•If you have lost fluids due to vomiting or diarrhoea, try a drink with electrolytes, such as ones developed for use after a workout. A pharmacist or your cancer team can suggest electrolyte drinks.

Unfortunately, such symptoms are common. At least four-fifths (80 per cent) of people with cancer experience fatigue during chemo- or radiotherapy, and most (60–90 per cent) regard fatigue as their most disabling symptom.83 Occasionally fatigue is so profound that patients discontinue treatments, contemplate suicide or wish for an early death.83 So how can you reduce fatigue’s impact?

There are numerous causes or contributors to cancer-related fatigue.12, 83, 87, 90

•Fatigue can emerge as your body recovers from surgery or as a side effect of chemo- or radiotherapy.

•Some cancers release chemical messengers that undermine your energy. When chemo- and radiotherapy destroy the cancer, the tumour might release a flood of chemicals into the blood that triggers sleep difficulties and fatigue.

•Disrupted sleep, anaemia, infections and poor nutrition can all cause or exacerbate fatigue.

•how bad the fatigue feels try ranking its severity on a scale of ‘0’ for no fatigue or tiredness to ‘10’ for the worst fatigue you have experienced or can imagine;

•how much the fatigue interferes with your daily life you could rank this from ‘0’ for no interference to ‘10’ for being unable to get out of bed or out of a chair;

•your sleep patterns this helps reveal any link between your fatigue and, for example, poor sleep hygiene or poorly controlled pain;

•your daily activities this helps identify any triggers in your lifestyle, such as trying to do too much or having too many visitors;

•what you have tried to address the fatigue and any improvement you could rate how well strategies have worked on a scale of ‘0’ for no improvement to ‘10’ if the fatigue resolved.

Unlike nausea, vomiting and pain, few drugs can help people with cancer-related fatigue, unless anaemia, an infection or depression contributes.87 Fatigue often improves after the cancer treatment ends and is worst early in the journey. It seems that as people learn to live with the cancer, they know what to expect – the severity of cancer-related fatigue sometimes comes as a shock – and what helps. This means that you need to take a proactive approach to dealing with fatigue.

Planning, prioritizing and pacing allow you to spend your time and energy on those activities that you value most or need to get done.83, 85, 87, 91

•List things that you have to do and what you can leave or ask someone else to do.

•Jot down who you can ask for help, for what and when (so that, for example, it fits into their commitments). Family and friends are usually more than willing to help, but often do not know what to do or feel uncomfortable asking. They could help by, for example, giving you a lift to hospital, looking after children, cooking or with the housework. Often your family and friends will feel better because they can do something.

•Your diary can help you strike the right balance between rest and activity. Plan your daily routine, which should include regular rest and relaxation. You might find that you need to add extra periods of rest before or after activity or visitors. Take a break if you feel you need to rest, even if it is unscheduled. Struggling on just makes matters worse. Nevertheless, excessive rest can sap your energy and interfere with sleep, so work out the ideal amount for you.

You might not always feel up to a workout, especially if you are fatigued, your muscles or joints ache or you feel depressed, yet regular exercise brings important benefits for people with cancer.12, 36, 68, 83, 84, 92

•Physical activity is, ironically, one of the best ways to counter fatigue. That is one reason why regular exercise helps you look after yourself and improves your quality of life.

•Exercise might reduce the impact on your body composition of the cancer and its treatment. Exercise, for example, strengthens muscles and bones, and improves heart and lung function.

•Exercise can help counter nausea and vomiting, sharpen your appetite, improve digestion and prevent constipation.

•Exercise might help prevent and alleviate lymphoedema (see page 111), ‘menopausal’ symptoms linked to hormonal treatments, and cancer-related cognitive impairment.

•Exercise might improve survival. For instance, women with breast cancer who reduced their physical activity after their malignancy was diagnosed were twice as likely to die in the next eleven years than those who maintained or increased their exercise levels.93

Speak to your cancer team before beginning exercise or physical activity. You might need to adapt your diet or you might be vulnerable to certain injuries. For example, people with skeletal metastasis or bone loss due to therapy should avoid activities that could increase the risk of fractures, such as jumping or twisting the hips. Chemotherapy-induced neuropathy might affect balance, which means you should exercise in a way that avoids the risk of falls.36

Here are a few more tips that might help you live with cancer-related fatigue.83, 85, 87, 91

•You could ask your cancer team or GP to refer you to an occupational therapist, who might be able to suggest changes that could be made to your home that could help conserve energy, such as grab rails, raising toilet seats or putting chairs near stairs.

•Overuse of painkillers, sedatives and some other drugs can cause or contribute to fatigue. If you suspect that a treatment could be a factor, speak to your cancer team. There is a usually an alternative. Never stop a treatment or reduce the dose, however, unless advised to do so by your cancer team.

•Some people find that fatigue undermines their memory and concentration. Try making notes, keep lists and stick to a routine.

•Try to distract yourself. Watch a DVD, read or listen to music or a podcast – anything that takes your mind off the cancer and your fatigue.

•After checking with your cancer team, try a CAM, such as yoga, mindfulness, meditation, guided imagery or progressive muscle relaxation.

•Think about your diet. Cells use a sugar called glucose as fuel. Digestion breaks complex carbohydrates into glucose more slowly than it breaks down simple sugars (such as the sugar in your tea), so you might find that eating, for instance, rice, chapattis, yams, noodles, cereals, pasta, potatoes and bread maintains your energy levels better than filling up on simple sugars.

Fatigue experienced by carers

Carers often endure profound tiredness and marked sleep disturbances. After all, caring for someone with cancer can be mentally, physically and emotionally exhausting. Carers:

•might need to prioritize demands on their time and plan accordingly;

•might benefit from stress and time-management techniques;

•should try to get enough rest and relaxation;

•should take part in activities they enjoy at least a couple of times a week;

•discuss respite care with the cancer team and the person with cancer – recharging your batteries will help improve the care you are able to give to the person with cancer.

Disturbed sleep in a person with cancer can have numerous causes, including that it is a:

Many of these can affect the sleep of carers as well as the person with cancer. In some cases, your cancer team can help, perhaps by adjusting your treatment. Hypnotics (sleeping pills) and insomnia treatments you buy without a prescription can help re-establish a normal sleep pattern, but they are only a short-term fix until the good sleep hygiene tips in the box ‘The principles of good sleep hygiene’ work. (Both people with cancer and their carers should follow these tips.) Either way, do not suffer in silence.

The principles of good sleep hygiene

•Although regular exercise helps you sleep and counter cancer-related fatigue, exercising just before bed can disrupt sleep.

•If you experience cancer-related fatigue, you should schedule rest regularly throughout the day. Try to avoid naps, however, as they can make sleeping at night more difficult.

•Avoid alcohol. A nightcap can help you fall asleep, but as blood alcohol levels fall, sleep becomes more fragmented and lighter, so you might wake repeatedly in the latter part of the night.

•Avoid stimulants, such as caffeine and nicotine, for several hours before bed. Try hot milk or milky drinks instead.

•During the day you should remain hydrated, but do not drink too much fluid – even non-alcoholic – just before bed as this can mean regular trips to the bathroom.

•Do not eat a heavy meal before bedtime.

•Go to bed at the same time each night and set your alarm for the same time each morning, even at weekends. This helps re-establish a regular sleep pattern.

•Make the bed and bedroom as comfortable as possible. If you can afford to, invest in a comfortable mattress, with enough bedclothes. Make sure the room is not too hot, too cold or too bright. Try adding ‘blackout’ linings to curtains if too much light comes through them.

•Do not worry about anything you have forgotten to do. Simply jot it down – keep a notepad by the bed if you find you do this a lot – then get back to sleep. Making a note in this way should help you forget about the thing you need to remember until the morning.

•Although this is, for many people, a counsel of perfection, try not to take your troubles to bed with you. Brooding makes things seem worse, exacerbates stress, keeps you awake and, because you are tired in the morning, means you are less able to deal with your difficulties. If you can, avoid heavy conversations and arguments before bed.

•Use the bed for sex and sleep only. Do not work or watch television.

Pain can have numerous causes, including the tumour, its treatments and the aftermath of an operation. Some diagnostic procedures can be uncomfortable or even painful. In addition:

•nurses administer many cancer treatments by infusion, which can cause pain, swelling and skin reactions around where the tube enters your vein (see page 60);

Unfortunately, pain does not always subside after treatment ends. A study that included people with a variety of cancers found that a fifth still reported pain at least two years after diagnosis.90 There is no need to suffer this in silence, however. Modern painkillers (analgesics) and other treatments can almost always adequately control cancer-related pain.

Make sure that your cancer team knows when and where the pain develops, as well as its severity. You could keep a diary. The team will also need to know the type of pain. A dull pain might have different causes and treatment from pins and needles, for example, even if they are equally unpleasant. So, note if the pain is dull and aching or sharp and stabbing. Does it feel like an electric shock or pins and needles? It is especially important to tell your cancer team if:87

•the pain is getting worse or the painkillers do not seem to work as well as they did;

Your doctor will probably begin by trying to control your pain using ‘simple’ painkillers, such as aspirin and paracetamol. If these prove inadequate, mild opioids (codeine) might be tried. Finally, you might be offered the strong opioids, such as morphine. You are extremely unlikely to become addicted if you follow the cancer team’s advice – they can reassure you if you are worried about dependence. Follow the team’s advice for painkillers, but, as a rule, take them regularly – such as every three to six hours – or as the pain begins to emerge. ‘Grinning and bearing’ the pain means that analgesics typically take longer to work.

Sometimes an operation or radiotherapy can alleviate pain. For example, surgeons or radiotherapy might remove or shrink a tumour that presses on a nerve. Surgeons can also cut certain nerves that carry the pain signal. Many people find that CAMs – such as hypnosis, acupuncture and massage – help control pain, but check with the cancer team first.

Some drugs and certain malignancies might damage nerves, which can lead to peripheral neuropathy. Tell your cancer team if you develop symptoms such as:

Peripheral neuropathy seems to be most common with vinca alkaloids, taxanes and platinum derivatives. The longest nerves are the most susceptible, which is why peripheral neuropathy usually affects the hands and feet. Indeed, severe peripheral neuropathy can undermine movement. Cisplatin can also damage nerves involved in hearing, which might cause partial deafness and tinnitus (ringing in the ears). In general, peripheral neuropathy abates over several months once treatment ends. Occasionally, however, symptoms persist for months or even years after your last course of chemotherapy.2, 3

In the meantime, analgesics and some other drugs might help. Some people find that avoiding alcohol and, as far as possible, repetitive activities that might stress nerves – such as golf, tennis, playing an instrument or using a computer keyboard – alleviates the discomfort. Some also benefit from CAMs, such as biofeedback, acupuncture, hypnosis and relaxation techniques.87

Some chemotherapies – including taxanes and vinca alkaloids – and certain cancers can cause painful joints (arthralgia) and muscles (myalgia). Often simple painkillers help. In addition, you could:87

•apply a heat pad, hot water bottle, an ice pack or a packet of frozen peas to the painful joint or muscle;

•soak in a warm bath (check with your cancer team before using aromatherapy essences as some might not be suitable and you need to make sure anything you add to your bath will not undermine your skin care);

Skin, hair and nail cells divide rapidly. You replace about 30,000 skin cells every minute, for instance.7 So, as with any rapidly dividing tissue, cancer treatment can take its toll on your skin, nails and hair.

Some cancer drugs, for example, might cause an area of dry, scaly skin. Some might trigger an itchy, red area. Others might cause pus-filled pimples that look like acne. Radiotherapy can mean that your skin blisters and peels, leaving moist red areas.91 Your cancer team can suggest steroids, antibiotics and other drugs that might help protect and heal your skin, and dressings that should speed the healing of any damage following radiotherapy.91 Mention any change in your skin to your cancer team.

•If you develop a skin reaction or have received radiotherapy, check which creams, cosmetics, medicines, tapes and plasters, and bath products you can use and ask if you should change any.

•Use a moisturizer regularly on dry skin. Check with the cancer team or radiotherapist which is the best one for you to use. You can swim after checking with the cancer team, but chlorine can dry skin, so use a moisturizer.

•Avoid long hot showers and baths. Wash in warm or tepid water and do not stay in too long.

•Make sure the house is not too warm and try a humidifier if the air seems dry.

•Avoid wool and synthetic fibres. Wear loose-fitting, soft cotton clothes. Wash sheets and clothing in mild detergents.

•Avoid wet shaving. Do not use hair-removal creams or wax, especially on the area being treated.

•If you develop diarrhoea, be particularly careful about personal hygiene: chemicals in faeces can damage the delicate skin around the anus.

Safe sun practices prevent most skin cancers, but you need to remain vigilant, especially if you are taking certain cancer treatments or have already had a skin malignancy. For example:94

•three-fifths (60 per cent) of people who have their first non-melanoma skin cancer develop another of these malignancies within ten years;

•if it is not their first, a similar proportion (62 per cent) develop another non-melanoma skin cancer within two years;

•if it is not their first, 9 in 10 (91 per cent) develop another non-melanoma skin cancer within a decade.

So keep an eye out for any changes to your skin. Examine your skin every month: a check only takes ten minutes or so. Take a selfie, use mirrors or ask a friend or family member to look at ‘difficult to view’ skin areas. You could mark the location of each mole, birthmark, bump, sore, scaly patch and so on on an outline of the body (<www.skincancer.org/skin-cancer-information/early-detection/body-map>) to help you identify any changes.

Your cancer team can tell you what to watch for, but if you are unsure, check and tell them or your GP if you see any of the following:

•a lesion (such as a spot, blemish or mole) that is growing, bleeding, changing in appearance or never heals completely;

Radiotherapy and some cancer treatments can leave your skin highly sensitive to the sun – so-called photosensitivity reactions. This means that you are much more likely to burn than you were before treatment. With some treatments the skin might be so sensitive that you get sunburn even indoors – through windows – or on cloudy days.91 So you might have to use suncream on cloudy days and during the winter. Ask your cancer team about the precautions you need to take.

You should also ask your cancer team for advice about the right sun protection factor (SPF) and sunscreen for you, but as a general rule, apply suncream with a SPF of 15 or more at least every two hours. Apply the suncream more frequently if you are sweating or swimming. Some people will need a minimum SPF of 30 and ideally 50, either because of a malignancy (in those who have had a skin cancer, for example) or its treatment (drugs that cause photosensitivity reactions, for instance).

Cover as much skin as possible, including your ears and any bald patches, and use a lip balm. In addition:

•wear a broad-brimmed hat, UV-protective sunglasses and clothing with a close weave that covers as much skin as possible;

•avoid direct sunlight as much as possible, especially from 11 a.m. to 3 p.m.;

•if you are particularly photosensitive, consider using window films that block UV in the home, office and car;

If you are receiving radiotherapy, skin reactions usually begin about a week after the start of the treatment, peak about a week after the radiotherapy ends and generally take two to six weeks to resolve. Fortunately, long-term effects on the skin are uncommon.3 To reduce skin damage during radiotherapy, try the tips listed below:3

•avoid excessive heat and cold during treatment by, for example, showering in warm water;

•tell your cancer team if you see a wound on your skin – several specialized wound dressings can aid healing;

Once again, cancer-related itchiness has several causes. For example, a cancer can release chemicals that trigger this. Often the irritation subsides if treatment shrinks the cancer. In other cases your bile duct can become blocked by a tumour. The build-up of bilirubin and other toxins can cause itchiness. Surgeons might be able to unblock a blocked bile duct or a doctor can prescribe a drug called cholestyramine, which binds the itch-promoting bile salts.

Your cancer team might suggest antihistamines. These block the action of histamine, a chemical messenger that triggers itchiness. Low doses of some drugs (used – at higher doses – to treat depression or epilepsy) might be especially helpful if peripheral neuropathy or other forms of nerve irritation are causing the itch. Doctors can also prescribe steroids as creams or tablets. These dampen the activity of the cells that trigger itchiness.

•Several CAMs – including acupuncture, hypnosis or relaxation therapy – may alleviate the intensity of the itch.

•Apply a cold pack or a packet of frozen peas to the itchy area. Some people find that rubbing, tapping or pressing the itchy area or gently pinching nearby skin helps.

•Apply an unscented and colourless moisturizer after bathing or when the itching is uncomfortable. Ask your cancer team or a pharmacist which is the best one for you to use.

•Do not take too many baths, do not spend longer than about 20 minutes in the bath and use lukewarm water.

•Use little or no soap; try a bathtime emollient suggested by your doctor, pharmacist or nurse instead.

•Pat skin dry with a towel rather than rub it – but dry yourself well to help reduce chafing and the risk of fungal infections.

•Drink 2–3 litres of fluid a day – dehydration can trigger or exacerbate itchiness.

•Keep rooms cool and humid – hot and dry atmospheres can make itchiness worse.

•Keeping your nails short and wearing soft cotton mittens and socks may help prevent skin damage if you cannot stop scratching, especially in your sleep.

•Avoid things that might make your itch worse, such as certain hair and cleaning products, scented products or preparations containing lanolin.

•Wearing loose-fitting cotton clothes often helps – wool and man-made fabrics can irritate the skin.

•Try to take your mind off the itch by watching television, listening to music, reading or whatever else distracts you.

People spend millions each year on manicures, false nails and polishes to make their nails attractive. Nails also protect your fingertips and, by supporting the other side of the finger, help you make precise, delicate movements and enhance the sensitivity of your touch.

Many people receiving chemotherapy find that their nails grow more slowly than usual and become fragile and brittle. The nails might lift from the bed and break easily or develop horizontal lines (Beau’s lines).3 Watch for any changes, such as separation of the nail from the nail bed, discolouration or an increase in milk spots.

The following tips might help to keep your nails in as good a condition as possible:

•keep your nails short, but do not push back the cuticle, which can increase the risk of infections, and do not have aggressive manicures or pedicures or bite your nails;

In general, nail symptoms resolve when treatment ends, but see your cancer team if you are experiencing pain or performing normal activities becomes more difficult.

Hair loss (alopecia) is, perhaps, the most familiar side effect of cancer treatment and can cause considerable distress.3

Healthy head hair grows by approximately 12 cm (5 inches) a year and you normally lose about 100 hairs a day. As we have seen, chemo- and radiotherapy target rapidly dividing cells, so losing a few more hairs is common during treatment for cancer. Do not worry, though, if you see a few extra hairs on our brush – you need to lose at least half your hair before anyone else will notice.87

Hair loss typically starts to happen two to three weeks after the first chemo- or radiotherapy treatment has been given, usually beginning on the crown and above the ears. In addition to scalp hair, you can lose beard, eyebrows and pubic and body hair.

Radiotherapy, especially to the brain and head, can cause hair loss. Hair regrowth following radiotherapy can be extremely slow and might be incomplete. Unless you have received very high levels of radiotherapy, hair normally grows back within three to five months of the end of treatment.

Sometimes regrowth begins before chemotherapy ends, but it might curl as it pushes through the scalp – sometimes called ‘chemo curl’ – and might be a different texture or colour than it was before treatment.3, 87

Speak to your cancer team, a counsellor or a patient support group if your hair loss causes you distress. The tips given below might help limit the impact:

•cut your hair short when you start treatment – any loss might seem less dramatic and you will regain your style more quickly afterwards;

•hair loss can leave skin sensitive or tender, even before the loss becomes visible, so be careful if you shave, depilate or cut hair anywhere on your body;

•brush your hair gently using a soft hairbrush, especially when it begins to regrow, and limit pinning, curling or blow-drying your hair at a high heat setting;

•avoid using chemicals (such as hair colour) until your hair has regrown and, if you do, test any chemical on a small patch of hair first and avoid hair colour for at least three months after your treatment ends;

•think about a wig or hairpiece – a hairdresser can help you style the wig or hairpiece, which you should have fitted properly to stop scalp irritation;

Up to 2 in 5 (40 per cent) of people with cancer overall and as many as 7 in 10 (70 per cent) of those with advanced cancer experience poor appetite and unintentional weight loss (anorexia).87 Cachexia (wasting of fat and muscle), which eventually emerges in up to half of people with cancer, usually develops slowly, beginning with weight loss over several months.95 Anorexia, weight loss and cachexia undermine people’s ability to cope with everyday activities, worsen quality of life, can reduce the effectiveness of some treatments and may shorten survival.87, 95

Several factors contribute to anorexia, weight loss and cachexia in people with cancer, including those listed below.

•The site of the tumour can play a role. For example, people with oesophageal, stomach, pancreatic and small cell lung cancers seem to be at especially high risk. Tumours in the oesophagus, for example, can leave the person feeling as if food is stuck in the throat and 4 in 5 patients with stomach or pancreatic cancer, 3 in 5 with lung or prostate cancer and 1 in 3 of those with breast cancer show marked weight loss over six months.83, 87, 95

•Between 5 and 9 in 10 people with advanced cancer report changes in taste and smell (see below), which, if severe, can put people off their food.83

•Depression, anxiety, constipation, dry mouth, mucositis (pain and inflammation of the lining of the gastrointestinal tract – see below), nausea and vomiting can make eating difficult.83

•Some medicines (for cancer and some other diseases) or radiotherapy result in a dry mouth (see below).36

It is important to speak to your cancer team. Managing symptoms and side effects, and making changes to your diet – including using nutritional supplements if appropriate – usually helps. In addition, light exercise an hour or two before eating can sharpen the appetite.83 You could walk around the block, for example.

People with cancer often feel full sooner than when they were healthy and may find eating five or six small meals a day easier than having three larger meals. Try to eat one or two of these meals with your family. If you cannot finish and your family is worried, remind them that you are eating more frequently. Keep healthy snacks – such as carrot sticks, slices of sweet peppers, fresh and dried fruits – by you for when you feel peckish.83

Many people with cancer find their senses of taste and smell change. This can arise, for example, as a symptom of head and neck cancer96 or as a side effect of radiotherapy to some parts of the body. Taste usually returns two to three months after radiotherapy ends.3

Taste changes seem to be especially common with chemotherapy: more than half (38–84 per cent in different studies) of patients receiving chemotherapy develop taste changes.96, 97 How many experience changes in their sense of smell due to chemotherapy is less clear.96 Many people with cancer – perhaps 1 in 10 (10 per cent) to three quarters (78 per cent) – report a metallic taste in their mouths.96, 97

The likelihood of developing taste changes depends on the drug used and may arise, for example, due to:

•changes in saliva and mucus production – some antidepressants, antihistamines and diuretics (water tablets) reduce saliva production leading to a dry mouth;

Often the sense of taste returns once chemotherapy ends,96 but you should tell the cancer team if you experience changes. In one study, about a third of patients reported a metallic taste. The oncologist was aware of the change in only about 1 in 10 cases.97

If you experience changes in your senses of taste and smell, the tips listed below may help (you might need to try more than one):3, 96, 97

Mucositis usually develops 7–14 days after treatment begins and typically lasts for 2–3 weeks after treatment ends. Mucositis and stomatitis might leave you susceptible to oral thrush (oral candidiasis), a fungal infection that causes uncomfortable white patches on the mouth and tongue. Candidiasis can lead to a loss of taste or there being an unpleasant taste in the mouth.87, 91

Speak to your cancer team if you develop any of these symptoms, which could arise from mucositis:

Bleeding gums

Some malignancies and cancer treatments can affect platelets (the blood cells responsible for clots), so contact your cancer team if you bleed excessively when you brush or floss. A dental check-up before starting cancer treatment can help address any issues that could get worse during treatment.91

Severe mucositis might need potent painkillers, intravenous fluids and tube feeding. Mouthwashes, less potent painkillers and barrier products can help with milder symptoms.3, 85–87, 91 In addition, you could take the following steps to relieve symptoms.3

•Rinse your mouth out with warm water with a little salt dissolved in it, sterile water or a non-alcoholic, unsweetened mouthwash after each meal and at bedtime. You could rinse with 1 teaspoon of salt or 1–2 teaspoons of baking soda in a litre of water. If you want to rinse more often, check which mouthwash to use and how often you should use it with your cancer team or dentist, who might be able to suggest mouthwashes that reduce the pain and inflammation.

•Gently brush and floss at least twice a day unless your doctor tells you otherwise. Use teeth sponges and a soft – or a child’s – toothbrush to clean your teeth; this helps reduce gum damage. You might find that a toothpaste for sensitive teeth is more comfortable than your usual brand.

•Zinc supplements (220 mg zinc sulphate twice daily) can reduce the severity of mucositis. Again, always check with your cancer team before taking supplements.

•The mouth is susceptible to fungal infections, such as thrush. Rinsing reduces the risk, but tell your cancer team if you notice any white patches. Antifungals can treat thrush infections.

•Tell your cancer team if your mouth is painful. A change to your painkillers often helps.

•Some people find that sucking ice cubes or an ice lolly alleviates the discomfort. You could also try this during chemotherapy – the approach is similar to using a cold cap to reduce alopecia.2

•A vitamin E supplement and ‘swish and swallow’ formulations of glutamine might reduce the frequency, severity and duration of oral mucositis. Tablets and other oral formulations of glutamine do not seem to be as effective as swish and swallow.

•Ask your cancer team about these and other antiseptic and anti-inflammatory mouthwashes, gels and so on. Your pharmacist or cancer team can suggest treatments for mouth ulcers and sores.

•Avoid spicy, salty or acidic foods, as well as raw vegetables, granola, toast and other ‘rough’ foods. If hot and warm foods irritate your mouth, eat cold foods or meals at room temperature. Try eating soft food, such as mashed potatoes, scrambled eggs, macaroni cheese, cottage cheese, soft fruits or purées, soups, milk and yogurt shakes.

•If you want to drink alcohol, avoid neat spirits. Some people find that tomato, grapefruit and some orange juices irritate their mouths. Drink plenty of water, if necessary using a straw or a bottle with a sports cap.

Apart from being uncomfortable, a dry mouth (xerostomia) can make speaking, chewing and swallowing difficult and can lead to, for example, halitosis (bad breath), recurrent mouth infections (including thrush), taste changes, tooth decay and gum disease.3, 91

Once again, dry mouth can arise from several causes – radiotherapy, for instance, can damage your salivary glands. In general, salivary glands start working properly three to four months after the end of radiotherapy, but if you received a large dose of radiation, dry mouth might last longer or even be permanent.91 Several cancers, certain drugs and dehydration can reduce saliva production.

If you develop dry mouth, try the tips given below, which might help (you may need to try more than one):3, 91

Sometimes damage to, or removal of parts of the lymphatic system (see page 7) can lead to fluid retention and tissue swelling. This reaction, called lymphoedema, causes swelling, usually in the limbs. The swelling may, however, extend to the groin, face, neck and genitals.

Lymphoedema can impair body image, sexuality, social activities and your ability to perform some jobs or activities around the house.87

If you develop lymphoedema, try one or more of the following strategies, which might help:87

•many people find that strengthening and aerobic exercises are especially helpful, but avoid heavy lifting (more than about 7 kilos/15 lbs) or vigorous repetitive movements against resistance;

•watch for any signs of an infection – such as a raised temperature – and speak to your GP or cancer team if you think you might have one;

•avoid keeping a swollen leg still for a long time, such as during a flight or car journey;

Some cancers and certain treatments can increase the chance of catching a viral, fungal or bacterial infection. Pyrexia (a high temperature) is part of the body’s natural response to infections. In addition, some cancers release chemicals that cause fever.

Pyrexia usually passes as your body adjusts – a bit like resetting the thermostat on your central heating. In the meantime, drugs such as paracetamol, ibuprofen or aspirin can help bring your temperature down and alleviate any pain and discomfort. You might need to take doses every four to six hours until your temperature returns to normal. Ask your cancer team which drug is best for you. You should not take aspirin, however, if, for example, you have a low count of platelets or are at risk of bleeding for other reasons.

•feel very unwell or your temperature is very high – such as over 39.4 °C (103 °F);

•you feel faint and lightheaded, which might be a sign that your blood pressure is low;

•changes to the pattern of, or the end of periods – fourth-fifths of women who are less than 25 years of age recover their normal menstrual cycles after chemotherapy ends; women who are more than 40 years of age are at higher risk of permanent menopause;

Men taking hormonal treatments, such as for prostate cancer, can experience some ‘menopausal’ symptoms, including hot flushes, sweating and breast tenderness. Doctors can prescribe drugs that can alleviate some of these symptoms.

You could try the suggestions given below, which may help to alleviate menopausal symptoms:

•a low-fat diet, which might reduce the severity and frequency of menopausal symptoms;87

•avoiding spicy foods, caffeine and excessive amounts of alcohol, which might reduce hot flushes;

•vitamin E might reduce the number of hot flushes triggered by hormonal treatments;12

•relaxation, acupuncture, quitting smoking, maintaining a healthy weight and regular exercise might reduce the severity and frequency of menopausal symptoms.87

Between 3 and 4 in 10 (30 and 40 per cent) of women with breast cancer experience persistent moderate to severe hot flushes. The sensation of intense heat begins, usually, in the chest then moves to the neck and face. Women might flush, sweat and experience heart palpitations. The symptoms typically last from several seconds to a few minutes. Hot flushes at night often disrupt sleep.98

Tell your cancer team if you experience hot flushes. Some drugs – including certain medicines used to treat depression – alleviate severe hot flushes, whether or not you experience mood disturbances. Indeed, antidepressants seem to reduce the frequency and severity of hot flushes in women with breast cancer by up to two-fifths (14–58 per cent) compared to an inactive placebo. Antidepressants used to treat hot flushes might cause side effects, however – including dry mouth, headache, constipation, nausea and loss of appetite – and might interact with other drugs you are taking for cancer and other ailments.99

•reducing stress – try relaxation techniques and other CAMs after checking with your cancer team;

•several studies, mainly of women with breast cancer, report that acupuncture reduces the severity and frequency of hot flushes, and, in many cases, sleep seemed to improve as the hot flushes abated.

Some people feel that eating foods rich in phyto-oestrogens and related chemicals called isoflavones – such as soy, chickpeas, mung beans, flax seeds and alfalfa sprouts – alleviates hot flushes. (Phyto-oestrogens are chemicals produced by plants that resemble the hormone and so bind to the same receptors – see page 66.) You can also buy phyto-oestrogen supplements. Several studies have assessed various formulations of phyto-oestrogens for hot flushes (among women undergoing treatment for breast cancer, for example), but there is currently little evidence that phyto-oestrogens reduce the risk compared to placebo.99 That said, foods rich in phyto-oestrogens are generally healthy, so you could always try them, after checking with your cancer team first. After all, phyto-oestrogens act as mild hormones, which means high doses of phyto-oestrogens might not be suitable for people with some hormone-sensitive cancers.

Sexual issues and worries about sexual performance associated with cancer and its treatment can cause considerable stress and affect relationships. Sexual difficulties might arise from:

•physical symptoms, such as vaginal dryness and erectile dysfunction (impotence).3

At least half of people with breast, prostate, colorectal and gynaecological cancers endure long-term sexual difficulties.87 For instance, 2 in 5 (42 per cent) of prostate cancer survivors and 1 in 5 (20 per cent) of breast cancer survivors reported changes in sexual interest. About half (46 per cent) of prostate cancer survivors and a third (31 per cent) of men with colorectal cancer experience erectile dysfunction.3 Despite being common, many people suffer in silence. Don’t. Speak to your cancer team – there’s often a lot they can do to help.

You should consider any impact on sexuality or fertility when deciding on treatment. Chemotherapy – especially combination treatment – can impair fertility, for example. The effects depend on the drug. Vinca alkaloids and anthracyclines tend to produce a short-lived reduction in sperm production, for example, while other drugs – such as cyclophosphamide and cisplatin – can reduce sperm counts for much longer.3 Regimens containing alkylating agents – such as those used to treat Hodgkin’s lymphoma – can cause sterility in 4 in 5 men (80 per cent) and 1 in 2 (50 per cent) women.2 Sperm take about 72 days to develop,100 so sperm counts typically decline over 2–3 months.2 In women, chemotherapy tends to reduce the number of viable oocytes (the cells that develop into eggs).3

If you want to start a family or have more children, ask about sperm banking or egg storage.87 Also, check when it is safe to have penetrative sex, especially if you have brachytherapy, surgery or radiotherapy to your pelvis.91

Radiotherapy to the pelvis can cause adhesions (bands of scars) that narrow or shorten the vagina. If you are having radiotherapy to the vagina, you can use a vaginal dilator, which is shaped like a tampon, to stretch the vagina, prevent adhesions and break up scar tissue. Regular sex also helps.91

•Fatigue can mean you feel too worn out to have sex – try the tips given on page 92.

•Avoid large meals if you think you are likely to have sex. Digestion diverts blood from other parts of your body – including your sexual organs – to your gut.

•Change position – your partner being on top can help prevent breathlessness or might relieve the pressure on sore parts of your body.

•Non-irritating lubricants – ask your pharmacist or cancer team – can help if you experience vaginal dryness.

•Living with stress, anxiety, depression and altered body image can affect desire and libido. If you get an erection during the night or in the morning, the cause might be more psychological than physiological. Relaxation, anti-stress techniques and advice from a counsellor or a patient group can often help if stress undermines your sex drive.

•Doctors can prescribe several drugs to help with impotence, but never buy any drug online. If you want to try a herbal treatment for impotence, check with your cancer team first to ensure that it does not interact with your treatment.

•Several drugs that lower blood pressure, certain treatments for depression and anxiety, and some other medicines can cause impotence. If you think that a drug might be causing or contributing to your dificulties, speak to your doctor – there is usually an alternative.

•Avoid anything that triggers nausea, which might include perfumes, aftershaves, scented candles and so on. Having a light snack before you expect to have sex could help by settling your stomach.

•Pain can make sex difficult. Take painkillers an hour before if you expect to have sex, try different positions and support painful areas with cushions or pillows.

•Spend time with your partner or go on ‘dates’. Some carers find that the increased opportunity to be intimate when looking after a survivor increases sexual desire. Consider making time with your partner a ‘priority’ when planning to cope with fatigue.

•Reassure your partner that you love and find him or her attractive despite any physical changes or side effects or having to care for physical needs.

•Discuss any fears or concerns you have about being intimate with your partner. If necessary, swallow your embarrassment and speak to the cancer team, a patient support group or a counsellor. They can reassure you if, for example, you are worried that being intimate might cause the cancer survivor pain.

•Be patient. It might take a few weeks for a person with cancer to get his or her sexual confidence back.

•Keep an open mind. You might have to find new ways to make love, such as being more forward, becoming the ‘dominant’ partner or using sex toys and lubricants. Sexual pleasure is not always about penetration; it is also about intimacy.

Talk to your cancer team, a counsellor or a patient support group if you feel these approaches are not making a difference.

Is it any wonder that people with cancer feel depressed about the cancer attacking their bodies? Is it any wonder they feel anxious about being a burden to their families or friends, the cancer recurring or financial difficulties? That so many people with cancer do not develop profound depression or anxiety amazes me. Some even manage to use their adversity as a springboard to personal growth.

Nevertheless, depression is common among people with cancer. In addition, brain tumours or metastases can cause psychiatric symptoms, such as depression, mania, hallucinations, anxiety or anorexia nervosa. Indeed, depression might be the only sign of a brain tumour.101 That is another reason why people with cancer need to get new or worsening depression checked.

Depression is much more debilitating, intrusive and distressing than a low mood or the ‘simple’ sadness that is natural when you face a life-transforming event, such as cancer. Depression is a profound, debilitating mental and physical lethargy, which is why it can make fatigue worse; a pervasive sense of worthlessness, despite evidence to the contrary; an intense, deep, unshakable, guilt and crushing sadness. As William Styron remarks in Darkness Visible, depression ‘remains nearly incomprehensible to those who have not experienced it in its extreme mode’.

The symptoms of depression differ from person to person. Nevertheless, doctors recognize several core symptoms. People with depression typically spend a considerable time ruminating about the past, for example, and feel guilty about mistakes, when they let others down and events and acts they regard as immoral or sinful. Some patients and carers might develop depression because they regard the cancer as ‘punishment’ for their sins.

The more of the symptoms listed in the box ‘Examples of the core symptoms of depression’ you have, the more likely you are to have depression, especially if they persist and interfere with your day-to-day life. See your GP as soon as you can if you have little interest or take little pleasure in doing things you used to enjoy or you feel down, depressed or hopeless for most of the day, every day, for more than two weeks. See your doctor urgently if:

•you lack the motivation to work towards your goals, to exercise or follow your treatment or fatigue plan;

•you hear voices in your head – which are usually critical or defamatory – or experience visual hallucinations (hallucinations can be symptoms of a very serious condition called psychotic depression; in addition, some brain cancers and certain medicines can trigger hallucinations).

Tragically, cancer patients are more likely to die as a result of suicide than those without a malignancy. Researchers combined results from 15 studies looking at the risk and presented their findings at the European Congress of Psychiatry in 2017. Cancer patients were half as much again (55 per cent) more likely to commit suicide than the general population or to die from suicide than from other causes (53 per cent), such as a traffic accident or sudden heart attack.

If you feel suicidal or are getting to the end of your tether, then see your GP, go to the accident and emergency department of your local hospital, speak to your cancer team or phone a helpline, such as:

Examples of the core symptoms of depression

Examples of the psychological symptoms of depression

•Considering suicide, self-harm or taking steps towards suicide.

•Continuous low mood or sadness.

•Feeling anxious or worried.

•Feeling hopeless and helpless.

•Feeling irritable and intolerant of others.

•Feeling guilty – especially if the guilt is excessive or unjustified.

•Feeling tearful or crying.

•Lack of interest in things or activities – especially if these were once important or enjoyable.

•Lacking motivation.

•Low self-esteem.

•Procrastination – finding it difficult to make decisions.

Examples of the physical symptoms of depression

•Change in appetite or weight (usually loss of weight, but can be weight gain).

•Changes to the menstrual cycle.

•Constipation.

•Feeling lethargic – moving more slowly than usual.

•Lack of energy.

•Loss of libido.

•Sleep disturbances, such as difficulty falling asleep at night or waking early in the morning.

•Speaking more slowly or less than usual.

•Unexplained aches and pains.

Examples of the social symptoms of depression

•Avoiding contact with friends and family.

•Avoiding social activities.

•Neglecting and not being interested in your hobbies and interests.

•Poor performance at work, such as poor concentration, lack of motivation, absenteeism.

•Issues in your home and family life.

Adapted from NHS Choices.

Depression affects the body, mind and emotions. For example, about two-thirds of people with depression develop somatic (physical) symptoms, such as:102–104

•digestive symptoms – nausea, diarrhoea or constipation – and stomach pain

These overlap with many symptoms of cancer or the side effects of certain treatments. Keeping a diary might help to distinguish symptoms of depression from those linked to the malignancy. For example, the aches and pains that arise as a somatic symptom of depression often seem to be ‘everywhere’ rather than affecting a specific part of the body, such as muscles or joints. You should always get any symptoms that are unpleasant, painful or limit your ability to perform the activities of daily living checked out.

Anxiety evolved to produce physical, mental and behavioural changes that warn us of, and help us deal with, potential dangers, such as walking alone late at night. Anxiety disorders arise when our natural ‘fear’ reaction is out of proportion to the threat, excessively prolonged or interferes with our everyday life.

Essentially, people with anxiety are highly sensitive to potential threats. Their enhanced fear response leaves them ‘hyper-aroused’ and sensitive. They might feel restless, panicky, on edge and irritable, and their heart may be racing or palpitating. They might have difficulty concentrating and sleeping, feel sweaty, dizzy, need to urinate a lot and suffer chest and abdominal pain.87 People with anxiety usually recognize that their concern is excessive.

Answering ‘yes’ to either of the questions below suggests that you might have anxiety.105

•During the past four weeks, have you been bothered by feeling worried, tense or anxious most of the time?

Anxiety increases mental alertness and heightens your senses to help you detect danger. Adrenaline and other chemicals flood your body. Your heartbeat increases; you breathe more rapidly; you sweat. Blood flows from your skin and your intestines to your muscles – that is why we go pale when stressed or frightened. Muscles surrounding the hair follicles tighten, causing goosebumps. The pupils dilate, so you are wide-eyed with fear.

This flood of chemicals can cause physical symptoms – hence phrases such as ‘sick with fear’, ‘the runs’ and ‘butterflies in the tummy’. Anxiety also causes symptoms that overlap with those caused by some cancers and certain side effects, such as tense, sore muscles, ‘pins and needles’ and shortness of breath. Keep a note of when and where the symptoms arise.

Post-traumatic stress disorder

People with cancer can develop post-traumatic stress disorder (PTSD) – the condition closely related to anxiety that also causes the shell shock endured by some of those in the armed services. Between 1 in 14 and 1 in 3 (7–35 per cent) people with breast cancer seem to develop symptoms of PTSD, such as experiencing painful memories, insomnia and flashbacks. Certain people seem to be especially prone to developing PTSD, including those who receive chemotherapy, and those who develop metastases and symptoms related to their cancer.106

People with PTSD often report flashbacks ‘out of the blue’ and vivid dreams and nightmares about the trauma, such as when they were told they had cancer or it had recurred, pain from the malignancy or its treatment or long stays in hospital. They typically avoid places and people that evoke memories of the cancer, refuse to speak about their experiences and feel constantly on guard or emotionally numb. PTSD can place a considerable strain on relationships and increases the risk of suicide, drug and alcohol abuse and aggression, so speak to your GP or cancer team and get help.

Begin by trying to identify why you feel anxious or depressed. Try to be specific rather than just saying ‘the cancer’. What particularly bothers you? Fear of death? Concerns regarding pain? Worries about recurrence? The impact on your family? Ask yourself what unanswered questions and unresolved issues you have in relation to the cancer and its treatment as both can cause stress and anxiety. Ask your cancer team or a charity for the answers to questions you have about the malignancy and its treatment.

Try to avoid becoming preoccupied with symptoms and watching for signs of recurrence. A stomach ache can still be just indigestion even when you have cancer. Indeed, anxiety can cause muscular aches and pains, which you might worry are signs of recurrence. Also, while carers need to watch for new signs and symptoms, asking too regularly can fuel anxiety.

If anxiety, PTSD or depression interferes with your daily life, speak to your GP or cancer team. They can address particular issues that may cause you to feel anxious, such as poorly controlled pain. They might also suggest antidepressants and anxiolytics. These do not cure depression or anxiety in the way that, for example, antibiotics cure bacterial infections, but might alleviate symptoms, offering you the opportunity to address the causes. Talking treatments often deal with thoughts and behaviours that trigger depression, anxiety or PTSD. In addition, numerous CAMs relieve anxiety, stress and depression. You can find out more in The Holistic Guide for Cancer Survivors (see Further reading) or by contacting patient groups.

You could also ask yourself what and who helped you get through difficult times in the past. Who and what made matters worse? You can draw on these resources and insights, which are often more extensive than you realize, to ease you along your cancer journey. Try to take part in more family and recreational activities, which can help take your mind off your troubles. Get out and about in nature, which seems to have an anti-anxiety action in addition to the benefits of exercise. Cut back on caffeine and alcohol, both of which can worsen anxiety. Drinking too much alcohol can also exacerbate depression.

Foods rich in pectin	Foods rich in potassium
Apple, peeled or as sauce, without spices	Apricot nectar
Asparagus tips	Asparagus tips
Avocados	Avocados
Banana	Bananas
Beetroot	Fish
Plain pasta	Peach nectar
Potatoes, baked, without skin	Potatoes, boiled or mashed, without skin
White bread
White rice