January 2003: Managing Treatment Side Effects

Increasing energy, decreasing hot flashes?

Question from Nancy: Dr. Gralow, what do you recommend to help increase energy? I've always had low energy, but it seems to be worse since I was diagnosed with breast cancer. I am on tamoxifen, but don't know if that contributes to it. I do know that tamoxifen gives me hot flashes. I'm also on Effexor, which helped for a while, but I've noticed an increase in hot flashes lately. Thanks for any advice you may have.

Answers —Julie Gralow, M.D.: Fatigue is a very common problem for women who've been diagnosed with breast cancer. In fact, it's probably the most common complaint that I get from my patients. One of the best recommendations I can make is to try to incorporate physical activity into your life. It may seem a little counterintuitive that exerting yourself physically will give you more energy. But take it slowly, and, over time, you'll probably find you're getting stronger. Science has shown that exercise can help combat fatigue.

Of course, there are lots of other contributors to fatigue besides breast cancer treatment. For one thing, you want to make sure you aren't anemic. You need to correct that if it's a problem. Having a good diet helps, too. Sleep disturbances are another common cause of fatigue. The hot flashes that you're having may be disrupting your sleep, and better management of the hot flashes could, in the end, help raise your energy level. Sometimes drugs can interfere with energy levels, and I'd be interested to know what other medications you might be taking.

Marisa Weiss, M.D., Breastcancer.org president and founder: Read more about fatigue.

What is "chemo brain"?

Question from Bonnie: What is "chemo brain"?

Answers —Julie Gralow, M.D.: Good question! Chemo brain is another common complaint. What we're really talking about is some fuzziness in processing things—memory problems, forgetting where you put your keys, things like that. It is documented that women on chemotherapy do have changes in cognition. Once the chemotherapy has ended, it generally improves significantly over time. However, some studies suggest that even a year later you might be able to detect some small changes.

Of course, with aging, we all have changes in our memory, and we all become forgetful. So when my patients complain about minor forgetfulness, I remind them that it's common for all of us. In some cases, the problem is really about being too busy and not having time to process things. So being well organized and a little less busy can sometimes help with memory problems.

Marisa Weiss, M.D., Breastcancer.org president and founder: When major disruptions in your life, like a breast cancer diagnosis, happen quickly, and are followed by surgery, chemo, radiation, and symptoms like hot flashes, fatigue and fear, it's to be expected that your ability to function properly will be shaken. Short-term memory is a delicate process that can easily be disrupted by all these changes.

Possible to slow down hair loss?

Question from WW: I just had my first chemo treatment, and my hair is starting to fall out. Is there anything that can slow down the loss? I don't think I can cope with total hair loss AND treatment.

Answers —Julie Gralow, M.D.: Hair loss is a common side effect of many chemotherapy agents, and many of them cause complete hair loss. However, the hair always grows back again at the end of chemotherapy. My patients have tried all kinds of shampoos and conditioners that purport to help with it, but I don't think I've ever seen one that's made much of a difference.

Some people have tried using ice caps on the scalp, and this might slow down hair loss. But, in general, significant hair loss still occurs. There's also some concern about shutting down blood flow to the scalp, which is what you're doing with the ice. If you happened to have a tumor cell in the scalp area, you could be isolating it from the effects of the chemotherapy. Because of this, some oncologists don't encourage ice caps. And, as I said before, while the caps may slow down hair loss, hair loss still occurs.

Again, remember that this is only a temporary side effect. Lots of times hair comes back thicker and curlier. In general, you'll start seeing some hair growth within a couple of months after the last chemotherapy treatment. Hair follicles are deep inside the scalp, so re-growth isn't visible right away.

Marisa Weiss, M.D., Breastcancer.org president and founder: There have been studies showing that women fear hair loss even more than loss of a breast. Being prepared for this unpleasant side effect of treatment can make a huge difference. This means knowing when your hair is likely to come out. It means getting a wig that you like, as well as alternatives like turbans, a scarf, a baseball cap, or a snuggly hat to wear during the time that you are without hair.

Many women can do very well with a synthetic wig that costs less than $100. I even have patients who have a full assortment of wigs: long, short, black, blonde, etc. They have just decided that they're going to try to have some fun with it. A support group is a good place to find out what the best solutions are, and it's a good place to get support through this tough problem. Hair loss is terrible, but at least it's only temporary.

Can tamoxifen cause memory problems?

Question from Nancy: Can tamoxifen cause memory problems?

Answers —Julie Gralow, M.D.: To the best of my knowledge, we don't have any conclusive studies showing that tamoxifen has significant effects on the brain. Lots of times, people who are on tamoxifen previously had chemotherapy, so they may still be feeling some effects of the "chemo brain" that can continue for many months after tamoxifen is started.

We know that tamoxifen has anti-estrogenic effects on breast tissue. However, it also can have some estrogen-like properties on other tissues, like the bones and the uterus. We really aren't sure what it does in the brain. It may have favorable, estrogen-like effects on the brain in terms of memory and cognition, or it may have some minor anti-estrogenic effects. This is the subject of some interesting studies that are currently underway.

Marisa Weiss, M.D., Breastcancer.org president and founder: It's important to keep asking these great questions, because it's your questions that drive the research that should be done.

Vaginal discharge from tamoxifen?

Question from Sue: I started taking tamoxifen in July after a mastectomy with no lymph node involvement. About six weeks into the treatment, I began experiencing a vaginal discharge at night. My doctor says it's the vagina reacting to the tamoxifen. I was on Premarin for years.

Answers —Julie Gralow, M.D.: Watery vaginal discharge is a known side effect of tamoxifen. Usually, it's not terribly troubling, although in some cases it can require a woman to wear a mini pad all the time. A bloody discharge, of course, absolutely needs to be mentioned to your health care providers, because this is not a typical tamoxifen side effect, and it should be evaluated immediately.

Marisa Weiss, M.D., Breastcancer.org president and founder: Some women who take tamoxifen have vaginal discharge. But just as many experience vaginal dryness. It's interesting that the same drug can produce such different effects in different women. For women who are struggling with a dry vagina, there are ways to make the vagina wetter and more receptive to sexual activity.

You can learn more about how to deal with vaginal dryness and other symptoms in the transcript from our online conferences on Intimacy, Sex and Your Love Life.

Helping mother cope with side effects?

Question from Leanne: What can we—adult daughters—do to help our mom cope with the chemo side effects?

Answers —Julie Gralow, M.D.: This is a great question! Being diagnosed with breast cancer and going through treatment is horribly disruptive, not only to the patient, but to the whole family. Every patient is different; therefore, suggestions about what you can do to help your mother through this very difficult time should be based on who your mother is, what kinds of treatments she's receiving, what symptoms she has, etc. Since fatigue is almost always a side effect of breast cancer treatment, I try to help my patients focus the energy they do have on the things that are most important to them. This means trying not to spend all their energy on housekeeping and running errands, but focusing it on quality things and some good physical activity. So I suggest that you offer to clean the house, go to the grocery store, or prepare meals that could be frozen and heated later. If your mother is willing, take care of some of the routine things for her, so she can focus on fun things.

Remember, too, that the emotional impact of a breast cancer diagnosis is profound, and depression is not uncommon. So focus on helping your mother get through this hard time emotionally. If you're not living in the same town she is, send your mother little reminders—like an e-mail or card saying, "I'm thinking of you." This goes for daughters, sons, friends, and coworkers. It's nice to know that people are thinking of you. If you do live nearby, realize that stopping by her house unexpectedly during a post-chemo day when she's not feeling well might not be such a good idea. Make sure you respect your mom's privacy when she may not be feeling well.

Marisa Weiss, M.D., Breastcancer.org president and founder: Another useful thing you can do is to help guard your mother's privacy. This might mean answering the phone and thanking people for calling, but letting them know that your mother needs to rest. It can also mean dealing with nosy neighbors, unsolicited invitations and unwanted gifts, so your mother won't have to. It could also involve letting people know that your mom got through surgery OK and that everything's fine, in order to keep incoming phone calls to a minimum.

Just being there, as Dr. Gralow says, is such a gift, and it's terrific that your mom has you in her life to make this time easier for her. One more good thing to do is to plan fun activities for the future to give your mother something to look forward to. This will help reassure her there is a future in front of her and that you expect her to be there to enjoy it.

You might also want to visit the Breastcancer.org Discussion Boards to get some advice from others who are going through similar experiences.

Dealing with chemotherapy nausea?

Question from Kate: I am on a course of CMF chemotherapy, and I was told not to expect much nausea, if any. However, after both treatments, I have been so nauseated that I've been unable to get out of bed for three days, despite being on Zofran, Compazine and Ativan. I am missing workdays, which is not good. What else can I do?

Answers —Julie Gralow, M.D.: Nausea and vomiting are common side effects of most chemotherapy regimens, and they vary from patient to patient. CMF absolutely can cause nausea and vomiting, and you clearly are having trouble with it, even though you're taking very good anti-nausea medications. Sometimes, nausea is caused by acid in the stomach: the body may have trouble tolerating stomach acid during chemotherapy, because the treatment can cause irritation of the whole lining of the gut. So when I have patients who've had a few cycles of chemotherapy and are on good anti-nausea drugs, but still complain of queasiness and nausea, I suggest an acid blocker. There are a number of agents that could help.

Sometimes doctors can also alter the way chemotherapy is given. Instead of large doses every three to four weeks, it can sometimes be split into smaller weekly doses. Another thing that helps some patients is acupuncture. The most important thing is to talk to your healthcare team—your chemotherapy nurses and oncologist—about the problems you're having. Have them look at all your medications and the way your chemotherapy is being given.

I once had a patient who was taking a naturopathic preparation for nausea, and she kept increasing the dose. The nausea kept getting worse. Ultimately, we realized she was taking in a lot of caffeine, which turned out to be causing the nausea. When she stopped, the nausea went away. It's important to look at everything you're taking and eating, because sometimes there might be something other than chemotherapy that's contributing to the nausea.

Marisa Weiss, M.D., Breastcancer.org president and founder: Communication is so important. Not just to let your health care team know that you're having this problem, but to let them know whether a solution is or is not working. It's not uncommon for there to be a lot of back and forth talk between you, your doctor, and your nurse to find the right combination of food, medication, and mindful activities that will help you feel well. The fear of nausea makes nausea much worse, as well, so this open dialog can really help.

Natural menopause after chemical?

Question from Linda: After going through chemical menopause, will I go through a natural one at a later date?

Answers —Julie Gralow, M.D.: By chemical menopause, I assume you mean that you've had chemotherapy-induced menopause. Sometimes the cessation of menstrual periods is temporary, and sometimes it's permanent, even if you're below the age at which you normally would have gone through menopause. So if you have chemotherapy-induced menopause and your periods later return, you will definitely go through natural menopause at some point in the future.

Chemotherapy-induced menopause is more common with some chemotherapy regimens than others. Women in their 30s are much less likely to undergo permanent, chemotherapy-induced menopause than women in their 40s. Older women are more likely to stop having periods after a few cycles of chemotherapy and not get them back.

Marisa Weiss, M.D., Breastcancer.org president and founder: You can learn more about natural and treatment-induced menopause, as well as medications that can cause menopause-like symptoms, in the Breastcancer.org Managing Menopausal Symptoms section.

Breathing exercises for well-being?

Question from Ruthy: I have heard that learning to breathe correctly can greatly assist in improving well-being during treatment. Have you heard this? And if so, where can I get information about it?

Answer —Marisa Weiss, M.D., Breastcancer.org president and founder: There are a lot of 'mindful measures' that can help ease different side effects. These include specific exercises, meditation, visualization, and prayer, as well as breathing. These strategies can also improve your energy and concentration, and ease fear. All of these measures focus on repetitive movements, or things that will produce a 'relaxation state.' In this state, you are breathing quietly and less frequently, and your heart rate and blood pressure are down.

Your hospital may offer lessons on meditation, Tai Chi or visualization. Visit Breastcancer.org's Complementary Medicine section for more information. There are also excellent books on these topics. One visualization book is by Jon Kabat-Zinn. Yoga classes are also quite popular and widely available. It might be fun to try some of these things with a close friend, or with someone who's also going through treatment. One thing about managing side effects is that it's no fun doing it alone!

Reducing hot flashes for ER-positives?

Question from Helanna: Is there an effective remedy for estrogen-receptor-positive breast cancer patients who are experiencing hot flashes? My oncologist wanted me to take Clonidine, but my last blood pressure check at the time of chemo was 80/55, and I was afraid to take medication that might reduce my already low blood pressure.

Answers —Julie Gralow, M.D.: Obviously, managing menopause without hormones is a topic of great interest to breast cancer survivors. Interestingly, even in estrogen-receptor-negative breast cancers, we tend to avoid prescribing estrogen for hot flashes, because a woman who has had one breast cancer is at higher than average risk for a second breast cancer and estrogen is associated with some increase in breast cancer risk. With respect to things that can help with hot flashes without using estrogen, 10 years ago the two best prescription treatments were probably Clonidine and Bellergal. Both have some benefit in helping with hot flashes, but generally cause their own side effects, which can be as bad as or worse than the hot flashes. You're absolutely right in being concerned about using Clonidine, which is an anti-hypertensive, if you already have a low blood pressure.

Over the last several years, we've had some very nice scientific studies evaluating newer agents that have fewer side effects, and, in many cases, offer more benefit in treating hot flashes. A class of antidepressant drugs, of which Effexor may be one of the most commonly used, has been shown to help a lot of women with hot flashes. Recently, the Mayo Clinic group has shown that a drug called Neurontin, which is used mostly to treat seizures, can, at low doses, also help hot flashes. It may be used with or instead of Effexor. Some people find benefit from taking 400 IU of Vitamin E at night.

Other things you can do, short of taking prescription medications, would be to limit your caffeine and alcohol intake, since both can increase hot flashes. Smoking and nicotine, being stimulants, can increase hot flashes as well. In terms of reducing hot flashes, exercise can help; so can the mindful measures and therapies that Marisa has just gone over. Also, do common-sense things like dressing in layers, so if you feel a hot flash coming on, you can kick off your shoes or take off your sweater.

Marisa Weiss, M.D., Breastcancer.org president and founder: Clearly, stress also contributes to hot flashes. Even if you can't experience things in a less stressful manner, sometimes just cutting out the non-urgent things in your life can make a difference. NOT rushing to a meeting can be helpful. You would be surprised how many things you treat as urgent can be handled in a different way. Not everything is an emergency. Our patients often tell us that getting breast cancer makes them reorder their priorities. Things that were not so important before become more important, and things that seemed very important before can become less important.

Help for nerve pain and stiffness?

Question from Becca: I have nerve pain in ankles and wrists, which my oncologist says is from the chemo (AC+Taxotere). I also take Arimidex. What could help with the pain and stiffness?

Answer —Julie Gralow, M.D.: Bone and muscle aches are side effects of both chemotherapy and hormonal therapy. We know that in some patients, for up to a year or two after completing a chemotherapy regimen such as AC and Taxotere, some bone and joint aches can persist. In general, we encourage—if the pain requires it—some mild anti-inflammatories, such as ibuprofen. We also encourage physical activity. We've seen in a recent study evaluating Arimidex and tamoxifen that non-specific muscle and bone aches and pains were seen more often in women receiving Arimidex than in those receiving tamoxifen. So it's possible that the Arimidex is contributing to the problem. We would treat it in much the same way; in other words, managing the symptoms with some gentle anti-inflammatories.

One thing that patients and healthcare providers want to make sure of is that bone or joint pain aren't related to a cancer recurrence. Maintaining good communication and letting your healthcare team know what kinds of pain you're having will help them sort out whether this is an anticipated side effect of treatment or whether it's something that deserves a little more evaluation. In patients who received Neupogen—which is a white blood cell growth factor— during chemotherapy, we have noted that bone pain is a common complaint, but that it does tend to get better over time. For patients who are currently on Neupogen, the pain can be quite severe. Sometimes the best treatment is to reduce the dose while making sure the white blood cell counts are still in a good range.

Sick to stomach after Neupogen?

Question from Tomcat: I've been getting four to five shots of Neupogen between chemo rounds. Soon after I get my injection, I get sick to my stomach. Is this normal? And can this medication build up in your system and make you sick?

Answers —Julie Gralow, M.D.: Getting sick to your stomach after Neupogen isn't a side effect that I'm used to hearing. I'm wondering if it could be due to something else, like the chemotherapy that you're on. Patients react differently to different drugs, though, so it's possible that your stomach upset is due to the Neupogen. If your stomach problems seem to be related to the timing of the Neupogen shots, communicate this to your healthcare team and see if the dose can be modified or reduced. Also, be sure to take a good look at other things that might be contributing to the problem.

Marisa Weiss, M.D., Breastcancer.org president and founder: This question points to the importance of good communication between you, your doctor, and your nurses. They cannot know how best to help you unless you give them some clues—report your symptoms, and express your concerns. It's good to call your healthcare provider with specific questions, and be prepared to describe a new symptom by noting when it began, where it is located, how long it lasted, what things made it worse or better, and what, if anything, made it go away.

It's also important to note whether there's any pattern to the symptoms you're experiencing. When you call your healthcare providers to report your symptoms, always tell them about any allergies you may have. Have the phone number of your pharmacy ready so a prescription can be easily called in. Let your doctor or nurse know how best to reach you—what phone numbers to call, how late they can return the call, and whether they can leave a message on your answering machine. All these little details in how you communicate can end up making a big difference in how you feel.

Treating and preventing arm swelling?

Question from Ann: What's the best way to treat (and prevent) painful arm swelling?

Answers —Julie Gralow, M.D.: Arm swelling after breast cancer treatment is something that can range from none at all to swelling that seriously interferes with your everyday life. In general, lymphedema—which is arm swelling after lymph node removal or radiation to the lymph node area—is something that occurs to different degrees in different patients. We're hoping that the new sentinel node biopsy techniques being used to evaluate breast cancer patients' lymph node involvement will decrease lymphedema overall in our breast cancer patients. Adding radiation on top of lymph node surgery increases the risk of lymphedema. Recurrence of breast cancer in the armpit area, or the axilla, can also set off arm swelling after a patient has had her lymph nodes evaluated and disrupted.

We generally recommend trying to avoid anything that can disrupt lymphatic flow to the arm. Therefore, we recommend that you not get your blood pressure taken on the arm of your lymph node surgery, and that you not have IVs placed on that side, or have blood drawn from that arm. Always wear gloves when gardening to help prevent cuts and scrapes that could lead to infection. And at the first sign of any redness or infection in that arm, report it promptly to your healthcare team. Antibiotics need to be started soon, because an infection in the arm on the side of the lymph node surgery may cause or increase lymphedema.

Marisa Weiss, M.D., Breastcancer.org president and founder: Keep in mind that your skin is one of your best friends when it comes to protecting you against lymphedema; it's a barrier against infection. So as Dr. Gralow said, do your best to avoid any cuts or scrapes in the garden where there's dirt, avoid burns while in the kitchen, avoid bug bites and poison ivy, and aggressive manicures—anything, that is, that can disrupt the integrity of your skin.

Now that it's winter, the air is often very dry. Many patients experience dry skin and dry hands at this time. For women who are experiencing side effects to their nails from Taxol, for example, the skin around the nail can also get very irritated. A good solution for dry, irritated skin is to use a lot of Eucerin cream, A & D ointment, or plain Vaseline on your hands at night and then put on thin, white, cotton gloves and wear them through the night for a good moisturizing treatment. You can get these gloves from the Vermont Country Store catalog online.

The experience of having breast cancer makes it much more important for you to take care of yourself in ways that you may never have done before. You are important, and you need to treat yourself that way.

You can read more about how to prevent and manage arm swelling in the Breastcancer.org section on Arm Lymphedema.

When can lymphedema show up?

Question from Jean: How soon after lymph node removal would signs of lymphedema be present?

Answer —Julie Gralow, M.D.: Sometimes lymphedema, which is a blockage of the lymphatic flow in the arm, occurs immediately after surgery. Swelling caused by the surgery itself can sometimes cause some arm swelling that will get better over time and may not be permanent. Unfortunately, lymphedema and problems with lymphatic drainage can occur any time after surgery. Generally speaking, if you're going to have problems, they will be noticed within the first year after surgery. However, infections, cuts, and many of the other things Marisa has just gone over can lead to lymphedema many years later. That's why it's important to be vigilant about your skin and your arm, even 10 years after your surgery.

Safe to fly after treatment?

Question from Birgitt: How safe it is to fly after lumpectomy, radiation, and lymph node removal? And how soon?

Answer —Julie Gralow, M.D.: There's no reason to restrict your travel after breast cancer treatment if you're feeling up to it. Usually, your surgeon might recommend just a few weeks of healing before taking a long trip. But what you're probably wondering about is the arm swelling that can occur as a result of the pressure changes that take place 35,000 feet up in an airplane. When you fly, however, doesn't affect your chances of swelling, so there's no restriction in terms of waiting a month or a year.

What I usually tell my patients is that if they're having trouble with arm swelling, they should see a physical therapist, preferably one who treats lymphedema, and get fitted for a special sleeve to wear on the plane. This sleeve will constrict the arm and prevent fluid from building up. If a patient has had lymph node surgery but hasn't had any trouble with swelling, then I usually don't recommend getting a sleeve, although some lymphedema specialists do recommend it. If a patient who normally doesn't have lymphedema notices that her arm gets puffy after flying, then it may be reasonable to get fitted for a sleeve to wear on future flights.

In general, if you do get a little puffy, massage can help. Work your way up the arm toward the shoulder, since this can help mobilize this fluid. Generally speaking, arm swelling will go down fairly soon after the end of your travels.

Fitness program for cancer survivors?

Question from Jaya: Dr. Gralow, could you please explain your exercise and fitness program for cancer survivors? I think starting a structured program may help lift my mood and take my mind off the treatment for a while.

Answer —Julie Gralow, M.D.: I think it's great that you're asking about fitness, and I would encourage you to find a way to incorporate some exercise into your daily routine. We have a group in Seattle called Team Survivor Northwest. It's an exercise and fitness program for all women affected by cancer. We have weekly workouts for women cancer patients and survivors at four hospitals in the Seattle area, so there are four going on around town every week. We have an exercise therapist at each workout to meet patients who are new to the program and help them set realistic goals. The exercise therapist also makes sure we're aware of any specific treatment-related issues that might affect a woman's ability to participate in exercise.

We also have walks and runs that meet in a couple of different places around Seattle a few times a week. And we have all kinds of special sessions and special events. We have a group that likes to do dragon boating, and we have a big team of dragon boaters. They get up very early in the morning, do their stretches, and get out on the lakes. Some women like to hike. Some women have climbed mountains around Seattle. We have women who like to ride bicycles, and we had a group recently that rode their bikes across the state of Washington. Some women find that swimming is one of the best activities for them. We even have a program that provides childcare during swim sessions, and where the swim is only open to cancer survivors. And since it's only open to women cancer survivors, any body image problems melt away because you're with women who know where you're coming from.

We offer such a wide variety of programs because we know that each woman is different. The most important thing is to find something you like so you'll keep doing it. Because exercise, during and after treatment for breast cancer, is one of the things you can do for yourself that can impact both physical and emotional health. Remember, too, that stretching can be quite beneficial immediately after surgery to get the range of motion in your arm back. Stretching may be the most vigorous exercise you can do at certain times during your treatment. Maybe something like gentle yoga, which gets you out there, gets you active, and keeps you limber and strong, would be good. You don't have to be doing anything terribly athletic-sounding in order to do your body a lot of good.

Radiation and long-term consequences?

Question from Allen: Does radiation to the breast cause any long-term consequences?

Answer —Marisa Weiss, M.D., Breastcancer.org president and founder: Radiation to the breast can be associated with both short-term and some long-term effects. These can include persistent firmness, heaviness, and tenderness of the breast. The breast can be rounder and sit higher than it used to. The ribcage directly under the breast area is slightly more likely to experience a fracture if someone hits you or you fall down. The risk of this is only 1% to 2%, though, and the ribs should heal normally. There is also a very small risk of scar tissue occurring in the lung directly under the chest wall. It's unlikely for this to cause any symptoms, but it can show up on a chest x-ray.

Old radiation therapy techniques were associated with a slightly increased risk of heart disease for women treated for breast cancer on the left side. However, with modern technology using three-dimensional treatment planning, and a doctor who embraces this new technique, the heart should be excluded from treatment fields. As a result, there should be no increased risk of heart problems. Radiation therapy given to the lymph node region can add to your risk of lymphedema on the arm of that side.

You can learn more about this important subject in the Breastcancer.org Radiation Therapy section.

More medicine to treat pain?

Question from Mary: Should I take medicine to counteract the pain I feel in my body post-treatment? I feel like I'm taking medicine all the time.

Answer —Julie Gralow, M.D.: The decision about how to treat pain depends on how severe it is and what we think is causing it. A diffuse, overall pain may not respond to medication, and by communicating with your healthcare team you may be able to get some general recommendations about non-medication treatments. Pain due to neuropathy from chemotherapy agents like Taxol would be treated with a different kind of therapy than pain due to nail problems, or hand and foot problems that can be caused by other kinds of chemotherapy. So knowing where the pain is and what's causing it should dictate what kind of treatment to use, if we decided to treat it.

Lots of times, pain after therapy is best treated by doing all kinds of healthy things for yourself like getting physical activity, doing the mindful therapies, improving your nutrition, etc. Chemotherapy takes a big toll on the body, and I agree that adding more medication to the mix isn't always the right thing to do. Getting the whole body into shape might be the best thing for this kind of pain.

Nail problems from chemo?

Question from Wild Heart: I had to be taken off Taxotere, as the side effects were terrible. I'm now on Xeloda, and my nails are green, back, and blue, and loose. Can you help me with this?

Answers —Julie Gralow, M.D.: Some chemotherapy agents can cause terrible nail problems. Often, the best recommendation is to keep nails filed down very short. If there's any hint that there might be an infection going on, sometimes the solution is reducing the dose of chemotherapy, or holding off for a while. We have a dermatologist at our institution who helps us deal with this problem, and some of the things he recommends include keeping the nails filed down, keeping them clean, and avoiding infection.

Marisa Weiss, M.D., Breastcancer.org president and founder: It's important to be careful when caring for your nails. Sometimes over-manipulation of the nail bed with home tools can make things worse. It may be a good idea to ask your doctor or nurse to show you exactly how to trim and file your nails.